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Stordeur F, Si Larbi AG, Le Neindre K, Ory J, Faibis F, Lawrence C, Barbut F, Lecointe D, Farfour E. A predictive score for the result of carbapenem-resistant Enterobacterales and vancomycin-resistant enterococci screening. J Hosp Infect 2024; 148:20-29. [PMID: 38490490 DOI: 10.1016/j.jhin.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND The duration of extensively drug-resistant bacteria (XDR) carriage depends on several factors for which the information can be difficult to recover. AIM To determine whether past screening and clinical results of patients can predict the results of subsequent screening. METHODS In total, 256 patients were retrospectively included from 10 healthcare centres in France from January 2014 to January 2022. We created a predictive clearance score, ranging from -5 to +7, that included the number of XDR species and the type of resistance detected in the sample, as well as the time from the last positive sample, the number of previous consecutive negative samples, and obtaining at least one negative PCR result in the collection. This score could be used for the upcoming rectal screening of a patient carrying an XDR as soon as the last screening sample was negative. FINDINGS The negative predictive value was >99% for score ≤0. The median time to achieve XDR clearance was significantly shorter for a score of 0 (443 days (259-705)) than that based on previously published criteria. CONCLUSION This predictive score shows high performance for the assessment of XDR clearance. Relative to previous guidelines, it could help to lift specific infection prevention and control measures earlier. Nevertheless, the decision should be made according to other factors, such as antimicrobial use and adherence to hand hygiene.
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Affiliation(s)
- F Stordeur
- Structure interne de gestion des risques, hygiène, qualité (SIGRHYQ), Centre Hospitalier Poissy-Saint-Germain en Laye, Poissy, France; Unité de prévention du risque infectieux (UPRI), AP-HP Sorbonne Université - Site Saint-Antoine, Paris, France; Centre régional en Antibiothérapie (CRAtb) Ile-de-France, Paris, France.
| | - A-G Si Larbi
- Service d'hémovigilance, Hôpital Foch, Suresnes, France
| | - K Le Neindre
- Microbiologie de l'environnement, AP-HP Sorbonne Université - Site Saint-Antoine, Paris, France; Service de Prévention & Contrôle de l'Infection, département des Agents Infectieux, CHU Caen Normandie, Caen, France
| | - J Ory
- Service de microbiologie et hygiène hospitalière, CHU Nîmes, Nîmes, France
| | - F Faibis
- Microbiologie, Grand Hôpital de l'est francilien (GHEF), site Jossigny, France
| | - C Lawrence
- Structure interne de gestion des risques, hygiène, qualité (SIGRHYQ), Centre Hospitalier Poissy-Saint-Germain en Laye, Poissy, France; Equipe opérationnelle d'hygiène, AP-HP Université Paris Saclay, site Raymond-Poincaré, Garches, France; Equipe de prévention des infections, Centre Hospitalier François Quesnay, Mantes-la-Jolie, France
| | - F Barbut
- Unité de prévention du risque infectieux (UPRI), AP-HP Sorbonne Université - Site Saint-Antoine, Paris, France; Microbiologie de l'environnement, AP-HP Sorbonne Université - Site Saint-Antoine, Paris, France; Centre National de Référence du Clostridioïdes difficile, Paris, France; INSERM, Faculté de Pharmacie de Paris, Université de Paris, Paris, France
| | - D Lecointe
- Service d'hygiène, Prévention et Contrôle des Infections, Centre Hospitalier Sud Francilien (CHSF), Corbeil-Essonnes, France
| | - E Farfour
- Service de Biologie Clinique, hôpital Foch, Suresnes, France
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Cimen C, Noster J, Stelzer Y, Rump A, Sattler J, Berends M, Voss A, Hamprecht A. Surface water in Lower Saxony: A reservoir for multidrug-resistant Enterobacterales. One Health 2023; 17:100606. [PMID: 37583366 PMCID: PMC10424258 DOI: 10.1016/j.onehlt.2023.100606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/17/2023] Open
Abstract
The emergence of extended-spectrum β-lactamase and carbapenemase-producing Enterobacterales (ESBL-E and CPE, respectively) is a threat to modern medicine, as infections become increasingly difficult to treat. These bacteria have been detected in aquatic environments, which raises concerns about the potential spread of antibiotic resistance through water. Therefore, we investigated the occurrence of ESBL-E and CPE in surface water in Lower Saxony, Germany, using phenotypic and genotypic methods. Water samples were collected from two rivers, five water canals near farms, and 18 swimming lakes. ESBL-E and CPE were isolated from these samples using filters and selective agars. All isolates were analyzed by whole genome sequencing. Multidrug-resistant Enterobacterales were detected in 4/25 (16%) water bodies, including 1/2 rivers, 2/5 water canals and 1/18 lakes. Among all samples, isolates belonging to five different species/species complexes were detected: Escherichia coli (n = 10), Enterobacter cloacae complex (n = 4), Citrobacter freundii (n = 3), Citrobacter braakii (n = 2), and Klebsiella pneumoniae (n = 2). Of the 21 isolates, 13 (62%) were resistant at least to 3rd generation cephalosporins and eight (38%) additionally to carbapenems. CPE isolates harbored blaKPC-2 (n = 5), blaKPC-2 and blaVIM-1 (n = 2), or blaOXA-181 (n = 1); additionally, mcr-9 was detected in one isolate. Two out of eight CPE isolates were resistant to cefiderocol and two to colistin. Resistance to 3rd generation cephalosporins was mediated by ESBL (n = 10) or AmpC (n = 3). The presence of AmpC-producing Enterobacterales, ESBL-E and CPE in northern German surface water samples is alarming and highlights the importance of aquatic environments as a potential source of MDR bacteria.
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Affiliation(s)
- Cansu Cimen
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
- University of Groningen, Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Janina Noster
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Yvonne Stelzer
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
| | - Andreas Rump
- University Institute for Medical Genetics, Klinikum Oldenburg, Oldenburg, Germany
| | - Janko Sattler
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Matthijs Berends
- University of Groningen, Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
- Certe Medical Diagnostics and Advice Foundation, Department of Medical Epidemiology, Groningen, the Netherlands
| | - Andreas Voss
- University of Groningen, Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, the Netherlands
| | - Axel Hamprecht
- Institute for Medical Microbiology and Virology, University of Oldenburg, Oldenburg, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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Espie M, Marek A, Farrugia L, MacLeod M, Bal AM. Carriage of multidrug-resistant carbapenemase-producing gram-negative bacteria in patients admitted to NHS Greater Glasgow and Clyde hospitals: Implications for treatment. J R Coll Physicians Edinb 2023; 53:247-251. [PMID: 37846745 DOI: 10.1177/14782715231205919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Infections caused by gram-negative carbapenemase-producing organisms (CPO) have become a global phenomenon. Screening of patients for CPO that was carried out at 48-h intervals enables early detection of carriers for infection control purposes and planning therapy. METHODS We investigated the bacterial flora detected on screening, the enzymes that conferred resistance and the proportion of patients who developed bacteraemia with CPO and their therapy. RESULTS In all, 27 patients had a positive screen for CPO. A small but significant (7.5%) proportion of patients were not detected on initial screening. Escherichia coli and Klebsiella were predominant. New-Delhi metallo β-lactamase and oxacillin carbapenemases were the main enzymatic mechanisms of resistance. Four (14.8%) patients developed bacteraemia with CPO (30- and 90-day survival 100% and 75%, respectively). CONCLUSION A single negative screen does not rule out colonisation. A significant proportion of patients colonised with CPO develop bacteraemia. Vigilance is needed to prevent the nosocomial spread of CPO.
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Affiliation(s)
- Megan Espie
- Department of Microbiology, Glasgow Royal Infirmary and Queen Elizabeth University Hospital, Glasgow, UK
| | - Aleksandra Marek
- Department of Microbiology, Glasgow Royal Infirmary and Queen Elizabeth University Hospital, Glasgow, UK
| | - Leonard Farrugia
- Department of Microbiology, Glasgow Royal Infirmary and Queen Elizabeth University Hospital, Glasgow, UK
| | - Mairi MacLeod
- Department of Microbiology, Glasgow Royal Infirmary and Queen Elizabeth University Hospital, Glasgow, UK
| | - Abhijit M Bal
- Department of Microbiology, Glasgow Royal Infirmary and Queen Elizabeth University Hospital, Glasgow, UK
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Rodríguez-Pallares S, Mateo-Vargas MA, Rodríguez-Iglesias MA, Galán-Sánchez F. Molecular characterization of consecutive isolates of OXA-48-producing Klebsiella pneumoniae: changes in the virulome using next-generation sequencing (NGS). Microbes Infect 2023; 25:105217. [PMID: 37716437 DOI: 10.1016/j.micinf.2023.105217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 09/18/2023]
Abstract
Little is known about the clonality of consecutive OXA-48 producing-Klebsiella pneumoniae isolates from the same patient and the possibility of changes in their virulomes over time. We studied the molecular characteristics of twenty OXA-48-producing K. pneumoniae consecutive isolates from six patients using whole-genome sequencing. The genomes were screened for antimicrobial resistance and virulence factor genes and for replicon groups. MLST and SNPs analysis was performed. MLST analysis found 3 STs: ST11 (n = 13; 65.0%); ST4975 (n = 5, 25.0%); ST307 (n = 2; 10.0%). AcrAb efflux pump, siderophore enterobactin and rcsAB capsule synthesis regulator were detected in all sequenced isolates. The regulator of mucoid phenotype A (rmpA) and rmpA2 were not detected. Isolates also carried type 3 fimbriae (n = 19; 95.0%), yersiniabactin (n = 15; 75.0%) and type 1 fimbriae (7; 35.0%). Type 3 fimbriae and yersiniabactin were lost and recovered in consecutive isolates of two patients, probably acquired by horizontal gene transfer. Our findings reveal that recurrent infections are due to the same isolate, with an average of 2.69 SNPs per month, with different virulence profiles, and that the acquisition of virulence factor genes over time is possible.
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Affiliation(s)
- Salud Rodríguez-Pallares
- UGC Microbiología, Hospital Universitario Puerta del Mar, Avda. Ana de Viya 21, 11009, Cádiz, Spain.
| | | | - Manuel A Rodríguez-Iglesias
- UGC Microbiología, Hospital Universitario Puerta del Mar, Avda. Ana de Viya 21, 11009, Cádiz, Spain; Universidad de Cádiz, Cádiz, Spain; Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Hospital Universitario Puerta del Mar, Avda. Ana de Viya 21, 11009, Cádiz, Spain
| | - Fátima Galán-Sánchez
- UGC Microbiología, Hospital Universitario Puerta del Mar, Avda. Ana de Viya 21, 11009, Cádiz, Spain; Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA), Hospital Universitario Puerta del Mar, Avda. Ana de Viya 21, 11009, Cádiz, Spain
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Roberts LW, Enoch DA, Khokhar F, Blackwell GA, Wilson H, Warne B, Gouliouris T, Iqbal Z, Török ME. Long-read sequencing reveals genomic diversity and associated plasmid movement of carbapenemase-producing bacteria in a UK hospital over 6 years. Microb Genom 2023; 9:mgen001048. [PMID: 37405394 PMCID: PMC10438816 DOI: 10.1099/mgen.0.001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/22/2023] [Indexed: 07/06/2023] Open
Abstract
Healthcare-associated infections (HCAIs) affect the most vulnerable people in society and are increasingly difficult to treat in the face of mounting antimicrobial resistance (AMR). Routine surveillance represents an effective way of understanding the circulation and burden of bacterial resistance and transmission in hospital settings. Here, we used whole-genome sequencing (WGS) to retrospectively analyse carbapenemase-producing Gram-negative bacteria from a single hospital in the UK over 6 years (n=165). We found that the vast majority of isolates were either hospital-onset (HAI) or HCAI. Most carbapenemase-producing organisms were carriage isolates, with 71 % isolated from screening (rectal) swabs. Using WGS, we identified 15 species, the most common being Escherichia coli and Klebsiella pneumoniae. Only one significant clonal outbreak occurred during the study period and involved a sequence type (ST)78 K. pneumoniae carrying bla NDM-1 on an IncFIB/IncHI1B plasmid. Contextualization with public data revealed little evidence of this ST outside of the study hospital, warranting ongoing surveillance. Carbapenemase genes were found on plasmids in 86 % of isolates, the most common types being bla NDM- and bla OXA-type alleles. Using long-read sequencing, we determined that approximately 30 % of isolates with carbapenemase genes on plasmids had acquired them via horizontal transmission. Overall, a national framework to collate more contextual genomic data, particularly for plasmids and resistant bacteria in the community, is needed to better understand how carbapenemase genes are transmitted in the UK.
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Affiliation(s)
- Leah W. Roberts
- European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI), Wellcome Genome Campus, Hinxton, UK
- Department of Medicine, University of Cambridge, England, UK
| | - David A. Enoch
- Clinical Microbiology & Public Health Laboratory, UK Health Security Agency, Cambridge, UK
| | - Fahad Khokhar
- Centre for Therapeutic Immunology and Infectious Diseases, University of Cambridge, Cambridge, UK
| | | | - Hayley Wilson
- Department of Medicine, University of Cambridge, England, UK
| | - Ben Warne
- Department of Medicine, University of Cambridge, England, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Theodore Gouliouris
- Department of Medicine, University of Cambridge, England, UK
- Clinical Microbiology & Public Health Laboratory, UK Health Security Agency, Cambridge, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zamin Iqbal
- European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI), Wellcome Genome Campus, Hinxton, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, England, UK
- Clinical Microbiology & Public Health Laboratory, UK Health Security Agency, Cambridge, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Darda VM, Iosifidis E, Antachopoulos C, Kirvasilis F, Zarras C, Haidich AB, Papakonstantinou E, Kontou A, Sdougka M, Roilides E. Modifiable risk factors associated with later gut decolonization of carbapenem-resistant Gram-negative bacteria in children: A prospective cohort study. J Hosp Infect 2023; 136:75-84. [PMID: 37075817 DOI: 10.1016/j.jhin.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Nosocomial infections caused by carbapenem-resistant gram-negative bacteria (CRGNB) are associated with increased mortality and prolonged hospitalization; thus, later CRGNB-decolonization has significant clinical and public health implications. AIM We investigated modifiable/ non-modifiable risk factors for CRGNB-later gut decolonization in children. METHODS We included CRGNB-carriers (1day-16years old), hospitalized in a tertiary-level hospital (2018-2019). Upon CRGNB-carriage detection, rectal-swab cultures were taken weekly, if patients were hospitalized and monthly after discharge for 12 months. CRGNB-decolonization was defined as three consecutive negative rectal-swab cultures obtained ≥1 week apart. Modifiable (treatment administered/medical devices) and non-modifiable (age/gender/comorbidities) risk factors were recorded. Cox regression for later CRGNB-decolonization was performed. FINDINGS One hundred thirty CRGNB-carriers were recorded. After 12 months, 5.4% remained carriers. Risk factors for later decolonization were immunosuppression (HR: 0.52, 95%CI: 0.31-0.87), carbapenems (HR: 0.52, 95%CI: 0.30-0.91), proton-pump inhibitors (PPIs) (HR: 0.39, 95%CI: 0.24-0.64) and their duration of use, duration of hospitalization (HR: 0.90, 95%CI: 0.81-0.92, per 10 days), number of re-admissions (HR: 0.90, 95%CI: 0.86-0.96), abdominal surgery (HR: 0.33, 95%CI: 0.17-0.65), urinary catheter (HR: 0.42, 95%CI: 0.24-0.76) and duration of steroid administration (HR: 0.86, 95%CI: 0.84-0.88, per 10 days). CONCLUSIONS Carbapenems, PPIs and their duration of use, duration of steroids use, immunosuppression, urinary catheter, re-admissions, duration of hospitalization, and abdominal surgery are associated with later CRGNB-decolonization among children. Paediatric patients at risk of later decolonization should be under targeted screening and preemptive contact precautions. Known carriers at risk of later CRGNB-decolonization should be under meticulously applied contact precautions for longer durations.
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Affiliation(s)
- Violetta-Magdalini Darda
- 3(rd) Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- 3(rd) Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece
| | - Charalampos Antachopoulos
- 3(rd) Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece
| | - Fotis Kirvasilis
- 3(rd) Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece
| | - Charalampos Zarras
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Anna Bettina Haidich
- Department of Hygiene and Epidemiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Aggeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki Greece
| | - Maria Sdougka
- Pediatric Intensive Care Unit, Hippokration General Hospital, Thessaloniki Greece
| | - Emmanuel Roilides
- 3(rd) Department Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, and Hippokration General Hospital, Thessaloniki, Greece.
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Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers. Eur J Clin Microbiol Infect Dis 2023; 42:229-254. [PMID: 36680641 PMCID: PMC9899200 DOI: 10.1007/s10096-023-04548-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
The clinical impact of infections due to extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacterales (Ent) has reached dramatic levels worldwide. Infections due to these multidrug-resistant (MDR) pathogens-especially Escherichia coli and Klebsiella pneumoniae-may originate from a prior asymptomatic intestinal colonization that could also favor transmission to other subjects. It is therefore desirable that gut carriers are rapidly identified to try preventing both the occurrence of serious endogenous infections and potential transmission. Together with the infection prevention and control countermeasures, any strategy capable of effectively eradicating the MDR-Ent from the intestinal tract would be desirable. In this narrative review, we present a summary of the different aspects linked to the intestinal colonization due to MDR-Ent. In particular, culture- and molecular-based screening techniques to identify carriers, data on prevalence and risk factors in different populations, clinical impact, length of colonization, and contribution to transmission in various settings will be overviewed. We will also discuss the standard strategies (selective digestive decontamination, fecal microbiota transplant) and those still in development (bacteriophages, probiotics, microcins, and CRISPR-Cas-based) that might be used to decolonize MDR-Ent carriers.
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Rabaan AA, Eljaaly K, Alhumaid S, Albayat H, Al-Adsani W, Sabour AA, Alshiekheid MA, Al-Jishi JM, Khamis F, Alwarthan S, Alhajri M, Alfaraj AH, Tombuloglu H, Garout M, Alabdullah DM, Mohammed EAE, Yami FSA, Almuhtaresh HA, Livias KA, Mutair AA, Almushrif SA, Abusalah MAHA, Ahmed N. An Overview on Phenotypic and Genotypic Characterisation of Carbapenem-Resistant Enterobacterales. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1675. [PMID: 36422214 PMCID: PMC9696003 DOI: 10.3390/medicina58111675] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 08/26/2023]
Abstract
Improper use of antimicrobials has resulted in the emergence of antimicrobial resistance (AMR), including multi-drug resistance (MDR) among bacteria. Recently, a sudden increase in Carbapenem-resistant Enterobacterales (CRE) has been observed. This presents a substantial challenge in the treatment of CRE-infected individuals. Bacterial plasmids include the genes for carbapenem resistance, which can also spread to other bacteria to make them resistant. The incidence of CRE is rising significantly despite the efforts of health authorities, clinicians, and scientists. Many genotypic and phenotypic techniques are available to identify CRE. However, effective identification requires the integration of two or more methods. Whole genome sequencing (WGS), an advanced molecular approach, helps identify new strains of CRE and screening of the patient population; however, WGS is challenging to apply in clinical settings due to the complexity and high expense involved with this technique. The current review highlights the molecular mechanism of development of Carbapenem resistance, the epidemiology of CRE infections, spread of CRE, treatment options, and the phenotypic/genotypic characterisation of CRE. The potential of microorganisms to acquire resistance against Carbapenems remains high, which can lead to even more susceptible drugs such as colistin and polymyxins. Hence, the current study recommends running the antibiotic stewardship programs at an institutional level to control the use of antibiotics and to reduce the spread of CRE worldwide.
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Affiliation(s)
- Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Public Health and Nutrition, The University of Haripur, Haripur 22610, Pakistan
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Pharmacy Practice and Science Department, College of Pharmacy, University of Arizona, Tucson, AZ 85716, USA
| | - Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa 31982, Saudi Arabia
| | - Hawra Albayat
- Infectious Disease Department, King Saud Medical City, Riyadh 7790, Saudi Arabia
| | - Wasl Al-Adsani
- Department of Medicine, Infectious Diseases Hospital, Kuwait City 63537, Kuwait
- Department of Infectious Diseases, Hampton Veterans Administration Medical Center, Hampton, VA 23667, USA
| | - Amal A. Sabour
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Maha A. Alshiekheid
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Jumana M. Al-Jishi
- Internal Medicine Department, Qatif Central Hospital, Qatif 635342, Saudi Arabia
| | - Faryal Khamis
- Infection Diseases Unit, Department of Internal Medicine, Royal Hospital, Muscat 1331, Oman
| | - Sara Alwarthan
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Ammam 34212, Saudi Arabia
| | - Mashael Alhajri
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Ammam 34212, Saudi Arabia
| | - Amal H. Alfaraj
- Pediatric Department, Abqaiq General Hospital, First Eastern Health Cluster, Abqaiq 33261, Saudi Arabia
| | - Huseyin Tombuloglu
- Department of Genetics Research, Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam 34221, Saudi Arabia
| | - Mohammed Garout
- Department of Community Medicine and Health Care for Pilgrims, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia
| | - Duaa M. Alabdullah
- Molecular Diagnostic Laboratory, Dammam Regional Laboratory and Blood Bank, Dammam 31411, Saudi Arabia
| | - Elmoeiz Ali Elnagi Mohammed
- Department of Clinical Laboratory Sciences, Prince Sultan Military College of Health Sciences, Dhahran 34313, Saudi Arabia
| | - Fatimah S. Al Yami
- Department of Medical Laboratory, King Fahad Military Medical Complex, Dhahran 34313, Saudi Arabia
| | - Haifa A. Almuhtaresh
- Department of Clinical Laboratories Services, Dammam Medical Complex, Dammam Health Network, Dammam 5343, Saudi Arabia
| | - Kovy Arteaga Livias
- Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima 15001, Peru
- Facultad de Medicina, Universidad Nacional Hermilio Valdizán, Huánuco 10000, Peru
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia
- College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
- School of Nursing, Wollongong University, Wollongong, NSW 2522, Australia
- Nursing Department, Prince Sultan Military College of Health Sciences, Dhahran 33048, Saudi Arabia
| | - Shawqi A. Almushrif
- Department of Microbiology and Hematology Laboratory, Dammam Comprehensive Screening Centre, Dammam 31433, Saudi Arabia
| | | | - Naveed Ahmed
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
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A Longitudinal Study of Spontaneous Gut Decolonization of Carbapenem-resistant Gram-negative Bacteria in Neonatal and Pediatric Patients. Pediatr Infect Dis J 2022; 41:648-653. [PMID: 35446811 DOI: 10.1097/inf.0000000000003562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotic exposure may convert gut microbiome to reservoir of resistant organisms, including carbapenem-resistant Gram-negative bacteria (CRGNB). Little is known about natural history of spontaneous CRGNB decolonization of neonates/children and their risk to develop CRGNB infections. METHODS Patients hospitalized in a tertiary care hospital (1 days to 16 years) found to be CRGNB colonized in weekly surveillance cultures during hospitalization (January 2018 to December 2019) were prospectively followed after discharge with monthly rectal cultures for 12 months after colonization until decolonization (3 consecutive negative rectal cultures, ≥1 week apart). Patient demographics, clinical characteristics and CRGNB infections were recorded. Polymerase chain reaction for carbapenemases was performed in patients colonized, after 3 negative cultures, at the day of the last negative and the day of the first new positive culture. RESULTS One-hundred thirty patients (median age, 1.3 months; lower-upper quartile values, 0.8-6.9 months) were studied including 66 neonates (median age, 12.6 days; Q1-Q3, 5-18.5 days). Among patients >30 days old, 51.6% achieved decolonization within 6 months, and among neonates, 91% achieved decolonization within 6 months. By 12th month, 89% of >30 days and 100% of neonates were decolonized. Forty-four (33.9%) patients (59% >30 days and 9% neonates) developed CRGNB infection(s), mainly pneumonia (25%) and bloodstream infection (20.5%). Prolonged colonization (odds ratio [OR], 7.75; 95% confidence interval [CI], 2.10-28.58), duration of broad-spectrum antibiotic use (OR, 1.22; 95% CI, 1.11-1.34) and parenteral nutrition (OR, 4.53; 95% CI, 1.14-17.94) were associated with the development of CRGNB infection. Two patients (1.5%) were found by polymerase chain reaction colonized after 3 negative cultures. CONCLUSIONS Spontaneous decolonization occurs in most CRGNB colonized >30 days and all neonates within 12 months. One-third of colonized patients develop CRGNB infection(s). These findings may help optimize duration of contact precautions and empirical antimicrobial therapy for CRGNB colonized pediatric patients.
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10
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Modelling of the transmission dynamics of carbapenem-resistant Klebsiella pneumoniae in hospitals and design of control strategies. Sci Rep 2022; 12:3805. [PMID: 35264643 PMCID: PMC8907197 DOI: 10.1038/s41598-022-07728-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 02/21/2022] [Indexed: 01/13/2023] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) has emerged as a major threat to global public health. Epidemiological and infection controls associated with CRKP are challenging because of several potential elements involved in a complicated cycle of transmission. Here, we proposed a comprehensive mathematical model to investigate the transmission dynamics of CRKP, determine factors affecting the prevalence, and evaluate the impact of interventions on transmission. The model includes the essential compartments, which are uncolonized, asymptomatic colonized, symptomatic colonized, and relapsed patients. Additionally, symptomatic colonized and relapsed patients were further classified into subpopulations according to their number of treatment failures or relapses. We found that the admission of colonized patients and use of antibiotics significantly impacted the endemic transmission in health care units. Thus, we introduced the treatment efficacy, defined by combining the treatment duration and probability of successful treatment, to characterize and describe the effects of antibiotic treatment on transmission. We showed that a high antibiotic treatment efficacy results in a significantly reduced likelihood of patient readmission in the health care unit. Additionally, our findings demonstrate that CRKP transmission with different epidemiological characteristics must be controlled using distinct interventions.
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11
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Effectiveness of selective digestive decolonization therapy using oral gentamicin for eradication of carbapenem-resistant Enterobacteriaceae carriage. Infect Control Hosp Epidemiol 2022; 43:1580-1585. [DOI: 10.1017/ice.2021.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objectives:
To evaluate the efficacy of selective digestive decolonization (SDD) therapy using oral gentamicin against carbapenem-resistant Enterobacteriaceae (CRE) colonization and to compare the incidence of novel gentamicin resistance between SDD and non-SDD patient groups.
Design:
Retrospective cohort study.
Setting:
Acute-care referral center hospital in South Korea.
Methods:
Adults aged ≥20 years identified as rectal CRE carriers hospitalized between October 2019 and June 2020 were enrolled. Patients with a <30-day follow-up were excluded. Among CRE carriers, those who received 80 mg oral gentamicin sulfate (Shin Poong Pharmaceutical, Seoul, South Korea) 4 times daily comprised the SDD group and those who did not receive SDD therapy comprised the non-SDD group. CRE decolonization was compared between groups within 15 days, and new gentamicin resistance was assessed.
Results:
In total, 73 rectal CRE carriers were identified; 11 patients were lost to follow-up within 30 days and were excluded. Oral gentamicin was administered to 20 of 62 patients. We detected no differences in the basic demographic features between groups. The rate of decolonization within 15 days was higher in the SDD group than in the non-SDD group (70.0% vs 23.8%; P = .001). The time to decolonization was significantly shorter in the SDD group. We detected no difference in acquisition of new gentamicin resistance between the groups. No serious adverse events due to oral gentamicin SDD therapy were reported.
Conclusions:
SDD therapy using oral gentamicin for CRE-colonized patients may be effective for the decolonization of gut CRE and for the prevention of transmission and subsequent CRE infection.
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12
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Abdelaziz NA. Phenotype-genotype correlations among carbapenem-resistant Enterobacterales recovered from four Egyptian hospitals with the report of SPM carbapenemase. Antimicrob Resist Infect Control 2022; 11:13. [PMID: 35063019 PMCID: PMC8783469 DOI: 10.1186/s13756-022-01061-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/11/2022] [Indexed: 02/07/2023] Open
Abstract
Background Carbapenem-resistant Enterobacterales (CRE), currently listed by the World Health Organization (WHO) as top priority critical pathogens, are a major global menace to human health. In low- and middle-income countries (LMICs) the threat is mounting fueled by selective pressures caused by antibiotic abuse and inadequate diagnostic resources. Methods This study phenotypically and genotypically characterized carbapenem resistance among 115 Enterobacterales isolates including 76 Klebsiella (K.) pneumoniae, 19 Escherichia (E.) coli, 14 Shigella (S.) sonnei, 5 Enterobacter (E.) cloacae, and 1 Proteus (P.) mirabilis. Results Ninety-three isolates (80.9%) were carbapenem-resistant with an alarming 57.5% carbapenem non-susceptibility in isolates collected from the outpatient department. Molecular characterization of the carbapenemases (CPases) encoding genes showed that blaNDM (80.5%) was the most prevalent; it was detected in 62 isolates (54 K. pneumoniae, 6 E. coli and 2 S. sonnei), followed by blaVIM (36.4%) which was observed in 28 isolates (24 K. pneumoniae, 3 E. coli and 1 E. cloacae). Other CPases included blaKPC (28.6%; in 20 K. pneumoniae, 1 E. coli and 1 S. sonnei), blaOXA-48 (26%; in 17 K. pneumoniae, 1 E. coli,1 E. cloacae and 1 P. mirabilis), blaIMP (6.5%; in 5 K. pneumoniae) and blaSPM (1.3%; in K. pneumoniae). Notably more than half of the Enterobacterales isolates (54.5%) co-harboured more than one CPase-encoding gene. Co-existence of blaNDM and blaVIM genes was the most dominant (31.2%), followed by association of blaNDM and blaKPC (24.7%), then blaVIM and blaKPC (13%). Moreover, the effects of different genotypes on meropenem MIC values were assessed, and a statistically significant difference between the genotype (Ambler classes A and B) and the genotype (Ambler classes B and D) was recorded. Conclusion The current findings may serve for a better understanding of the context of CRE in Egypt, associated drivers and CPases. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01061-7.
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Affiliation(s)
- Neveen A Abdelaziz
- Department of Microbiology and Immunology, Faculty of Pharmacy, Ahram Canadian University, POB: 12451, Sixth of October City, Giza, Egypt.
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13
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Viehweger A, Blumenscheit C, Lippmann N, Wyres KL, Brandt C, Hans JB, Hölzer M, Irber L, Gatermann S, Lübbert C, Pletz MW, Holt KE, König B. Context-aware genomic surveillance reveals hidden transmission of a carbapenemase-producing Klebsiella pneumoniae. Microb Genom 2021; 7:000741. [PMID: 34913861 PMCID: PMC8767333 DOI: 10.1099/mgen.0.000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Genomic surveillance can inform effective public health responses to pathogen outbreaks. However, integration of non-local data is rarely done. We investigate two large hospital outbreaks of a carbapenemase-carrying Klebsiella pneumoniae strain in Germany and show the value of contextual data. By screening about 10 000 genomes, over 400 000 metagenomes and two culture collections using in silico and in vitro methods, we identify a total of 415 closely related genomes reported in 28 studies. We identify the relationship between the two outbreaks through time-dated phylogeny, including their respective origin. One of the outbreaks presents extensive hidden transmission, with descendant isolates only identified in other studies. We then leverage the genome collection from this meta-analysis to identify genes under positive selection. We thereby identify an inner membrane transporter (ynjC) with a putative role in colistin resistance. Contextual data from other sources can thus enhance local genomic surveillance at multiple levels and should be integrated by default when available.
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Affiliation(s)
- Adrian Viehweger
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Leipzig, Germany
- *Correspondence: Adrian Viehweger,
| | | | - Norman Lippmann
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Leipzig, Germany
| | - Kelly L. Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Christian Brandt
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Jörg B. Hans
- National Reference Center for multidrug-resistant Gram-negative bacteria, Department for Medical Microbiology, Ruhr-University Bochum, Bochum, Germany
| | - Martin Hölzer
- Methodology and Research Infrastructure, MF1 Bioinformatics, Robert Koch Institute, Berlin, Germany
| | - Luiz Irber
- Department of Population Health and Reproduction, University of California, Davis, Davis, California, USA
| | - Sören Gatermann
- National Reference Center for multidrug-resistant Gram-negative bacteria, Department for Medical Microbiology, Ruhr-University Bochum, Bochum, Germany
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany
| | - Mathias W. Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Kathryn E. Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Brigitte König
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Leipzig, Germany
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14
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Extended-Spectrum Beta-Lactamase-Producing and Carbapenem-Resistant Enterobacterales in Companion and Animal-Assisted Interventions Dogs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412952. [PMID: 34948564 PMCID: PMC8700946 DOI: 10.3390/ijerph182412952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022]
Abstract
Animal-assisted interventions (AAIs) are being implemented in many countries for the beneficial effects they have on humans. Patients involved in AAI are often individuals at greater risk of acquiring infections, and these activities involve close contact between humans and animals, as is the case with humans living with a pet. The spread of multidrug-resistant Enterobacterales is a serious problem for human health; an integrated One Health strategy is imperative to combat this threat. Companion dogs can be a reservoir of multidrug-resistant pathogens, and animal-to-human transmission could occur during AAI sessions. The aim of this review was to collect the available data on the carriage of extended-spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in companion dogs and in an AAI context. Several papers have generally addressed the issue of microbial transmission during AAIs. Studies on the intestinal carriage of extended-spectrum beta-lactamase and/or carbapenem-resistant Enterobacterales have mainly been conducted in companion animals while few data are available on the carriage in dogs participating in AAI sessions. This review aims to draw attention to the antibiotic resistance problem in a One Health context and to the importance of extending infection control measures to this human-animal interface, to keep the balance of benefits/risks for AAIs shifted towards the benefits of these activities.
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15
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Within patient genetic diversity of bla KPC harboring Klebsiella pneumoniae in a Colombian hospital and identification of a new NTE KPC platform. Sci Rep 2021; 11:21409. [PMID: 34725422 PMCID: PMC8560879 DOI: 10.1038/s41598-021-00887-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
Resistance to carbapenems in Klebsiellapneumoniae has been mostly related with the worldwide dissemination of KPC, largely due to the pandemic clones belonging to the complex clonal (CC) 258. To unravel blaKPC post-endemic clinical impact, here we describe clinical characteristics of 68 patients from a high complexity hospital, and the molecular and genetic characteristics of their 139 blaKPC—K.pneumoniae (KPC-Kp) isolates. Of the 26 patients that presented relapses or reinfections, 16 had changes in the resistance profiles of the isolates recovered from the recurrent episodes. In respect to the genetic diversity of KPC-Kp isolates, PFGE revealed 45 different clonal complexes (CC). MLST for 12 representative clones showed ST258 was present in the most frequent CC (23.0%), however, remaining 11 representative clones belonged to non-CC258 STs (77.0%). Interestingly, 16 patients presented within-patient genetic diversity of KPC-Kp clones. In one of these, three unrelated KPC-Kp clones (ST258, ST504, and ST846) and a blaKPC—K.variicola isolate (ST182) were identified. For this patient, complete genome sequence of one representative isolate of each clone was determined. In K.pneumoniae isolates blaKPC was mobilized by two Tn3-like unrelated platforms: Tn4401b (ST258) and Tn6454 (ST504 and ST846), a new NTEKPC-IIe transposon for first time characterized also determined in the K.variicola isolate of this study. Genome analysis showed these transposons were harbored in different unrelated but previously reported plasmids and in the chromosome of a K.pneumoniae (for Tn4401b). In conclusion, in the blaKPC post-endemic dissemination in Colombia, different KPC-Kp clones (mostly non-CC258) have emerged due to integration of the single blaKPC gene in new genetic platforms. This work also shows the intra-patient resistant and genetic diversity of KPC-Kp isolates. This circulation dynamic could impact the effectiveness of long-term treatments.
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16
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Zhang W, Feng Y, Zhao H, Yan C, Feng J, Gan L, Cui J, Liu S, Zhang R, Du S, Li N, Xu W, Han J, Li R, Xue G, Yuan J. A Recombinase Aided Amplification Assay for Rapid Detection of the Klebsiella pneumoniae Carbapenemase Gene and Its Characteristics in Klebsiella pneumoniae. Front Cell Infect Microbiol 2021; 11:746325. [PMID: 34616692 PMCID: PMC8488121 DOI: 10.3389/fcimb.2021.746325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/20/2022] Open
Abstract
Klebsiella pneumoniae carbapenemase genes (blaKPC) play an important role in carbapenem-resistant Enterobacteriaceae in China. A rapid detection method for blaKPC genes and investigations into the molecular characteristics of blaKPC positive Klebsiella pneumoniae were necessary. In this study, an easy and rapid recombinase aided amplification assay (RAA) for blaKPC was established. This protocol could be completed at 39°C in 15–20 min. The sensitivity of this assay was determined as 48 copies per reaction, and the specificity was 100%. The blaKPC RAA method could be used for clinical diagnosis and epidemiological investigation. Among 801 fecal samples from inpatients, 34 blaKPC positive isolates were identified from each sample, of which 23 isolates were K. pneumoniae. ST11 with blaKPC-2 was the most prevalent type. All these strains were multidrug resistant and carried various virulence genes. Fecal carriage of blaKPC positive carbapenem-resistant K.pneumoniae poses significant challenges for public health control.
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Affiliation(s)
- Weiwei Zhang
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, China.,Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Yanling Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Hanqing Zhao
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Chao Yan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Junxia Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Lin Gan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Jinghua Cui
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Shiyu Liu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Rui Zhang
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Shuheng Du
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Nannan Li
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Wenjian Xu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Juqiang Han
- Department of Daily Clinic, Seventh Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Rongkuan Li
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, China
| | - Guanhua Xue
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Jing Yuan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
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17
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Jimenez A, Fennie K, Munoz-Price LS, Ibrahimou B, Pekovic V, Abbo LM, Martinez O, Rosello G, Sposato K, Doi Y, Trepka MJ. Duration of carbapenemase-producing Enterobacteriales carriage among ICU patients in Miami, FL: A retrospective cohort study. Am J Infect Control 2021; 49:1281-1286. [PMID: 34146625 DOI: 10.1016/j.ajic.2021.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current recommendations by the Centers for Disease Control and Prevention suggest placing patients with carbapenem-producing Enterobacteriales (CPE) in contact precautions, but there is no consensus on the appropriate duration of precautions. AIM We aimed to evaluate predictors for prolonged CPE carriage and median clearance time. METHODS Patients with first isolated CPE identified from 2012-2016 were followed for clearance of CPE using at least two rectal or tracheal aspirate surveillance cultures and clinical cultures during intensive-care-unit admission. Predictors associated with prolonged CPE carriage were assessed using Cox proportional-hazards. RESULTS Out of 75 eligible patients, 25 (33%) cleared their CPE-carrier status; median time to clearance was 80 days (Range, 16-457). Patients who were immunocompromised, had mechanical ventilation exposure, or exposure to carbapenems had 66%, 66%, and 86% (HR, 0.34, 0.34, and 0.14, respectively [P-value <.05]) lower probability of clearing compared to those immunocompetent of without such exposures. Patients with CPE isolated from more than one body site had a 5.3 times higher probability of clearing their CPE-carrier status (P-value <.001). CONCLUSIONS Patients immunocompromised, with mechanical ventilation exposure, or exposure to carbapenems had higher risk for prolonged CPE carriage. Infection prevention programs should consider these predictors as part of their assessment of discontinuing contact precautions among CPE carriers to prevent horizontal transmission and outbreaks within healthcare facilities.
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Affiliation(s)
- Adriana Jimenez
- Department of Infection Prevention and Control, Jackson Health System, Miami, FL; Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL.
| | | | - L Silvia Munoz-Price
- Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin Milwaukee, WI
| | - Boubakari Ibrahimou
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Vukosava Pekovic
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Lilian M Abbo
- Department of Infection Prevention and Control, Jackson Health System, Miami, FL; Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Octavio Martinez
- Department of Pathology and Laboratory Medicine, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Gemma Rosello
- Department of Infection Prevention and Control, Jackson Health System, Miami, FL
| | - Kathleen Sposato
- Department of Infection Prevention and Control, Jackson Health System, Miami, FL
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA; Departments of Microbiology and Infectious Diseases, Fujita Health University School of 14Medicine, Toyoake, Aichi, Japan
| | - Mary Jo Trepka
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
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18
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Kernéis S, Lucet JC, Santoro A, Meschiari M. Individual and collective impact of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in patients admitted to the ICU. J Antimicrob Chemother 2021; 76:i19-i26. [PMID: 33534878 DOI: 10.1093/jac/dkaa494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
KPC-producing Klebsiella pneumoniae (KPC-Kp) raises major concerns in the context of intensive care, owing to limited treatment options and the ability to cause outbreaks in this specific setting. The objectives of this review are to give an overview of the burden of KPC-Kp in ICU patients and to discuss methodological issues and limitations regarding the quality of data available. Robust and reliable assessment of the KPC-Kp impact in the ICU should take into consideration not only characteristics of the individuals, but also of the health systems including length of stay, costs and hospital organization issues. Estimates of mortality reported in the current literature are weakened by the poor quality of adjustment for age-specific risks, co-morbidities, and appropriateness of therapy. All these confounding factors should be taken into account in models, with consideration of control groups and competing risks that is currently lacking in the published literature. Since development of antibiotic resistance is an unstoppable phenomenon and economic and human resources are facing progressive limitations due to budget constraints, cost-saving strategies targeted to avoid ICU closure, temporary limitation of admissions or delayed hospital discharge are necessary. The early identification of KPC-Kp-colonized patients through active screening strategies is likely to be the cornerstone of such a cost-saving strategy. However, there are still many open issues concerning which of these strategies are the most effective. Owing to extreme heterogeneity and several methodological flaws in current publications, future studies investigating the long-term sequelae and economic impact of KPC-Kp in the ICU are urgently needed.
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Affiliation(s)
- Solen Kernéis
- Université de Paris, INSERM, IAME, F-75018, Paris, France.,Equipe de Prévention du Risque Infectieux, APHP, Hôpital Bichat, F-75018, Paris, France
| | - Jean Christophe Lucet
- Université de Paris, INSERM, IAME, F-75018, Paris, France.,Equipe de Prévention du Risque Infectieux, APHP, Hôpital Bichat, F-75018, Paris, France
| | - Antonella Santoro
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
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Mączyńska B, Paleczny J, Oleksy-Wawrzyniak M, Choroszy-Król I, Bartoszewicz M. In Vitro Susceptibility of Multi-Drug Resistant Klebsiellapneumoniae Strains Causing Nosocomial Infections to Fosfomycin. A Comparison of Determination Methods. Pathogens 2021; 10:512. [PMID: 33922754 PMCID: PMC8145326 DOI: 10.3390/pathogens10050512] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Over the past few decades, Klebsiella pneumoniae strains increased their pathogenicity and antibiotic resistance, thereby becoming a major therapeutic challenge. One of the few available therapeutic options seems to be intravenous fosfomycin. Unfortunately, the determination of sensitivity to fosfomycin performed in hospital laboratories can pose a significant problem. Therefore, the aim of the present research was to evaluate the activity of fosfomycin against clinical, multidrug-resistant Klebsiella pneumoniae strains isolated from nosocomial infections between 2011 and 2020, as well as to evaluate the methods routinely used in hospital laboratories to assess bacterial susceptibility to this antibiotic. MATERIALS AND METHODS 43 multidrug-resistant Klebsiella strains isolates from various infections were tested. All the strains had ESBL enzymes, and 20 also showed the presence of carbapenemases. Susceptibility was determined using the diffusion method (E-test) and the automated system (Phoenix), which were compared with the reference method (agar dilution). RESULTS For the reference method and for the E-test, the percentage of strains sensitive to fosfomycin was 65%. For the Phoenix system, the percentage of susceptible strains was slightly higher and stood at 72%. The percentage of fosfomycin-resistant strains in the Klebsiella carbapenemase-producing group was higher (45% for the reference method and E-test and 40% for the Phoenix method) than in carbapenemase-negative strains (25%, 25%, and 20%, respectively). Full (100%) susceptibility categorical agreement was achieved for the E-test and the reference method. Agreement between the automated Phoenix system and the reference method reached 86%. CONCLUSIONS Fosfomycin appears to be the antibiotic with a potential for use in the treatment of infections with multidrug-resistant Klebsiella strains. Susceptibility to this drug is exhibited by some strains, which are resistant to colistin and carbapenems. The E-test, unlike the Phoenix method, can be an alternative to the reference method in the routine determination of fosfomycin susceptibility, as it shows agreement in terms of sensitivity categories and only slight differences in MIC values. The Phoenix system, in comparison to the reference method, shows large discrepancies in the MIC values and in the susceptibility category.
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Affiliation(s)
- Beata Mączyńska
- Department of Pharmaceutical Microbiology and Parasitology, Faculty of Pharmacy, Medical University, 50-367 Wroclaw, Poland; (J.P.); (M.O.-W.); (M.B.)
| | - Justyna Paleczny
- Department of Pharmaceutical Microbiology and Parasitology, Faculty of Pharmacy, Medical University, 50-367 Wroclaw, Poland; (J.P.); (M.O.-W.); (M.B.)
| | - Monika Oleksy-Wawrzyniak
- Department of Pharmaceutical Microbiology and Parasitology, Faculty of Pharmacy, Medical University, 50-367 Wroclaw, Poland; (J.P.); (M.O.-W.); (M.B.)
| | - Irena Choroszy-Król
- Department of Basic Sciences, Faculty of Health Sciences, Medical University, 50-367 Wroclaw, Poland;
| | - Marzenna Bartoszewicz
- Department of Pharmaceutical Microbiology and Parasitology, Faculty of Pharmacy, Medical University, 50-367 Wroclaw, Poland; (J.P.); (M.O.-W.); (M.B.)
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Prolonged Carriage of Carbapenemase-Producing Enterobacteriaceae: Clinical Risk Factors and the Influence of Carbapenemase and Organism Types. J Clin Med 2021; 10:jcm10020310. [PMID: 33467637 PMCID: PMC7830152 DOI: 10.3390/jcm10020310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/29/2020] [Accepted: 01/12/2021] [Indexed: 12/25/2022] Open
Abstract
Prolonged carriage of carbapenemase-producing Enterobacteriaceae (CPE) constitutes a substantial epidemiologic threat. This study aimed to evaluate whether the types of carbapenemase and organism can affect the duration of carriage and to evaluate the clinical factors associated with prolonged carriage. We retrospectively reviewed data for patients admitted between May 2013 and August 2018 who were identified as CPE carriers. A total of 702 patients were identified; the major types of carbapenemase and organism were Oxacillinase (OXA)-48-like (n = 480, 68.4%) and Klebsiella pneumoniae (K. pneumoniae) (n = 584, 83.2%). The analyses of time to spontaneous decolonization using the Kaplan–Meier method showed that OXA-48-like and K. pneumoniae were significantly associated with prolonged carriage (log rank, p = 0.001 and p < 0.001). In multivariable logistic analysis to assess the risk factors for CPE prolonged carriage in the 188 patients with available follow-up culture data for 3 months, K. pneumoniae (adjusted odds ratio [aOR] 6.58; 95% confidence interval [CI], 1.05–41.27; p = 0.044), CPE positive clinical specimen (aOR 11.14; 95% CI, 4.73–26.25; p < 0.001), and concurrent Clostridioides difficile infection (CDI) (aOR 3.98, 95% CI 1.29–12.26; p = 0.016) were predictive of prolonged carriage. Our results suggest that CP-K. pneumoniae may have higher probability of prolonged carriage, while the effect of OXA-48-like CPE is inconclusive. Furthermore, patients with CP-K. pneumoniae who had positive clinical specimen or concurrent CDI can cause a vicious circle in prolonged carriage.
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Jatzkowski S, Rimek D, Popp A, Schmidt N, Reuss A. Prävalenz von multiresistenten gramnegativen Erregern bei Bewohnern von stationären Pflegeeinrichtungen 2019 in Thüringen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1454-1459. [DOI: 10.1007/s00103-020-03236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
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Wendt R, Nickel O, Botsch A, Lindner M, Bethge A, Marx K, Ruf BR, Beige J, Lübbert C. Low colonization rates with Multidrug-resistant Gram-negative bacteria in a German hospital-affiliated hemodialysis center. PLoS One 2020; 15:e0240314. [PMID: 33057439 PMCID: PMC7561126 DOI: 10.1371/journal.pone.0240314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/23/2020] [Indexed: 12/02/2022] Open
Abstract
Background Multidrug-resistant Gram-negative bacteria (MDRGN) are found with rising prevalence in non-hemodialysis risk populations as well as hemodialysis (HD) cohorts in Asia, Europe and North America. At the same time, colonization and consecutive infections with such pathogens may increase mortality and morbidity of affected individuals. We aimed to monitor intestinal MDRGN colonization in a yet not investigated German HD population. Methods We performed cross-sectional point-prevalence testing with 12 months follow-up and selected testing of relatives in an out-patient HD cohort of n = 77 patients by using microbiological cultures from fresh stool samples, combined with Matrix Assisted Laser Desorption Ionization—Time of Flight Mass Spectrometry (MALDI-TOF-MS) and antimicrobial susceptibility testing. Results We detected MDRGN in 8 out of 77 patients (10.4%) and 1 out of 22 relatives (4.5%), indicating only colonization and no infections. At follow-up, 2 patients showed phenotypic persistence of MDRGN colonization, and in 6 other patients de-novo MDRGN colonization could be demonstrated. Pathogens included Escherichia coli and Klebsiella pneumoniae (with extended-spectrum beta-lactamase [ESBL]-production as well as fluoroquinolone resistance), Stenotrophomonas maltophilia and Enterobacter cloacae. Conclusions In a single-center study, MDRGN colonization rates were below those found in non-HD high-risk populations and HD units in the US, respectively. Reasons for this could be high hygiene standards and a strict antibiotic stewardship policy with evidence of low consumption of fluoroquinolones and carbapenems in our HD unit and the affiliated hospital.
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Affiliation(s)
- Ralph Wendt
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
- Kuratorium for Dialysis and Transplantation (KfH) Renal Unit, Hospital St. Georg, Leipzig, Germany
| | - Olaf Nickel
- Department of Laboratory Medicine and Microbiology, Hospital St. Georg, Leipzig, Germany
| | - Almut Botsch
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Margareta Lindner
- Department of Laboratory Medicine and Microbiology, Hospital St. Georg, Leipzig, Germany
| | - Angela Bethge
- Department of Laboratory Medicine and Microbiology, Hospital St. Georg, Leipzig, Germany
| | - Kathrin Marx
- Hospital Pharmacy, Hospital St. Georg, Leipzig, Germany
| | - Bernhard R. Ruf
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
| | - Joachim Beige
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
- Kuratorium for Dialysis and Transplantation (KfH) Renal Unit, Hospital St. Georg, Leipzig, Germany
- Martin-Luther-University Halle/Wittenberg, Halle, Germany
| | - Christoph Lübbert
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
- Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, Leipzig, Germany
- * E-mail:
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Borgmann S, Rieß B, Meintrup D, Klare I, Werner G. Long-Lasting Decrease of the Acquisition of Enterococcus faecium and Gram-Negative Bacteria Producing Extended Spectrum Beta-Lactamase (ESBL) by Transient Application of Probiotics. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176100. [PMID: 32825711 PMCID: PMC7503522 DOI: 10.3390/ijerph17176100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Stefan Borgmann
- Hospital of Ingolstadt, Department of Infectious Diseases and Infection Control, D-85049 Ingolstadt, Germany;
- Correspondence: ; Tel.: +49-841-880-2020
| | - Beate Rieß
- Hospital of Ingolstadt, Department of Infectious Diseases and Infection Control, D-85049 Ingolstadt, Germany;
| | - David Meintrup
- Technische Hochschule Ingolstadt, Faculty of Engineering and Management, D-85049 Ingolstadt, Germany;
| | - Ingo Klare
- National Reference Centre for Staphylococci and Enterococci, Robert Koch Institute, Wernigerode Branch, D-38855 Wernigerode, Germany; (I.K.); (G.W.)
| | - Guido Werner
- National Reference Centre for Staphylococci and Enterococci, Robert Koch Institute, Wernigerode Branch, D-38855 Wernigerode, Germany; (I.K.); (G.W.)
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Hilliquin D, Lomont A, Zahar JR. Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory? J Hosp Infect 2020; 105:S0195-6701(20)30197-3. [PMID: 32315668 DOI: 10.1016/j.jhin.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination. AIM/METHODS We conducted a narrative review of the literature and discussed the role of cohorting. FINDINGS CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated. CONCLUSION Local epidemiology and resources must be assessed before implementing cohorting.
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Affiliation(s)
- Delphine Hilliquin
- Unité d'hygiène et d'épidémiologie, Hôpital Édouard Herriot, GH Centre, Hospices civils de Lyon, France; Université Lyon 1 Claude Bernard, Lyon, France.
| | - Alexandra Lomont
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
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25
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Integrating multiple genomic technologies to investigate an outbreak of carbapenemase-producing Enterobacter hormaechei. Nat Commun 2020; 11:466. [PMID: 31980604 PMCID: PMC6981164 DOI: 10.1038/s41467-019-14139-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 12/02/2019] [Indexed: 12/19/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) represent an urgent threat to human health. Here we report the application of several complementary whole-genome sequencing (WGS) technologies to characterise a hospital outbreak of blaIMP-4 carbapenemase-producing E. hormaechei. Using Illumina sequencing, we determined that all outbreak strains were sequence type 90 (ST90) and near-identical. Comparison to publicly available data linked all outbreak isolates to a 2013 isolate from the same ward, suggesting an environmental source in the hospital. Using Pacific Biosciences sequencing, we resolved the complete context of the blaIMP-4 gene on a large IncHI2 plasmid carried by all IMP-4-producing strains across different hospitals. Shotgun metagenomic sequencing of environmental samples also found evidence of ST90 E. hormaechei and the IncHI2 plasmid within the hospital plumbing. Finally, Oxford Nanopore sequencing rapidly resolved the true relationship of subsequent isolates to the initial outbreak. Overall, our strategic application of three WGS technologies provided an in-depth analysis of the outbreak. Antibiotic-resistant bacteria are an urgent threat to human health. Here, Roberts et al. characterise and monitor an ongoing hospital outbreak of carbapenemase-producing Enterobacter hormaechei by integrating several technologies for whole-genome sequencing and shotgun metagenomics.
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26
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Macesic N, Gomez-Simmonds A, Sullivan SB, Giddins MJ, Ferguson SA, Korakavi G, Leeds D, Park S, Shim K, Sowash MG, Hofbauer M, Finkel R, Hu Y, West J, Toussaint NC, Greendyke WG, Miko BA, Pereira MR, Whittier S, Verna EC, Uhlemann AC. Genomic Surveillance Reveals Diversity of Multidrug-Resistant Organism Colonization and Infection: A Prospective Cohort Study in Liver Transplant Recipients. Clin Infect Dis 2019; 67:905-912. [PMID: 29718144 DOI: 10.1093/cid/ciy199] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/22/2018] [Indexed: 01/30/2023] Open
Abstract
Background Multidrug-resistant organisms (MDROs) are an important cause of morbidity and mortality after solid organ transplantation. We aimed to characterize MDRO colonization dynamics and infection in liver transplant (LT) recipients through innovative use of active surveillance and whole-genome sequencing (WGS). Methods We prospectively enrolled consecutive adult patients undergoing LT from March 2014 to March 2016. Fecal samples were collected at multiple timepoints from time of enrollment to 12 months posttransplant. Samples were screened for carbapenem-resistant Enterobacteriaceae (CRE), Enterobacteriaceae resistant to third-generation cephalosporins (Ceph-RE), and vancomycin-resistant enterococci. We performed WGS of CRE and selected Ceph-RE isolates. We also collected clinical data including demographics, transplant characteristics, and infection data. Results We collected 998 stool samples and 119 rectal swabs from 128 patients. MDRO colonization was detected in 86 (67%) patients at least once and was significantly associated with subsequent MDRO infection (0 vs 19.8%, P = .002). Child-Turcotte-Pugh score at LT and duration of post-LT hospitalization were independent predictors of both MDRO colonization and infection. Temporal dynamics differed between MDROs with respect to onset of colonization, clearance, and infections. We detected an unexpected diversity of CRE colonizing isolates and previously unrecognized transmission that spanned Ceph-RE and CRE phenotypes, as well as a cluster of mcr-1-producing isolates. Conclusions Active surveillance and WGS showed that MDRO colonization is a highly dynamic and complex process after LT. Understanding that complexity is crucial for informing decisions regarding MDRO infection control, use of therapeutic decolonization, and empiric treatment regimens.
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Affiliation(s)
- Nenad Macesic
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Angela Gomez-Simmonds
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Sean B Sullivan
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York.,Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center
| | - Marla J Giddins
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York.,Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center
| | - Samantha A Ferguson
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Gautam Korakavi
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - David Leeds
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Sarah Park
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Kevin Shim
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Madeleine G Sowash
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Melanie Hofbauer
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Ryan Finkel
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Yue Hu
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Jared West
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | | | - William G Greendyke
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Benjamin A Miko
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Marcus R Pereira
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Susan Whittier
- Clinical Microbiology Laboratory, Department of Pathology and Cell Biology
| | - Elizabeth C Verna
- Division of Digestive and Liver Disease, Columbia University Medical Center, New York, New York
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York.,Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center
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27
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Köhler AT, Rodloff AC, Labahn M, Reinhardt M, Truyen U, Speck S. Evaluation of disinfectant efficacy against multidrug-resistant bacteria: A comprehensive analysis of different methods. Am J Infect Control 2019; 47:1181-1187. [PMID: 31060869 DOI: 10.1016/j.ajic.2019.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Multidrug-resistant gram-negative bacteria (MDR-GNB) constitute a threat to health care worldwide. Disinfectants are used to prevent and control the spread of MDR-GNB in a hospital setting but their efficacy might be impaired by bacterial mechanisms that may act on both antimicrobials and disinfectants. Determination of minimum inhibitory concentrations is mainly used to determine bacterial susceptibility against disinfectants, but practical tests on surfaces might be more suitable to predict in-use conditions. Our objective was to compare and evaluate 4 different methods widely used to assess surface disinfectant efficacy. METHODS The efficacy of benzalkonium chloride (BAC), peracetic acid (PAA), and ethanol (ETH) against multidrug-resistant Acinetobacter, Pseudomonas, and Klebsiella strains was assessed by minimum inhibitory concentration determinations, quantitative suspension tests, qualitative suspension tests, and carrier tests. Test results were compared to ascertain the most appropriate method. RESULTS ETH, PAA, and BAC were highly effective against MDR-GNB, but we observed marked differences in efficacious concentrations (up to 100-fold) as a function of the test method applied. Minimum inhibitory concentration determination was not reliable for evaluating susceptibility or resistance to BAC. CONCLUSIONS Surface tests should be used to determine bacterial susceptibility against disinfectants. Moreover, suitable guidelines are needed that allow for the standardization and comparison of bactericidal values obtained by different investigators.
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28
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Zhao Y, Zhang X, Torres VVL, Liu H, Rocker A, Zhang Y, Wang J, Chen L, Bi W, Lin J, Strugnell RA, Zhang S, Lithgow T, Zhou T, Cao J. An Outbreak of Carbapenem-Resistant and Hypervirulent Klebsiella pneumoniae in an Intensive Care Unit of a Major Teaching Hospital in Wenzhou, China. Front Public Health 2019; 7:229. [PMID: 31552210 PMCID: PMC6736603 DOI: 10.3389/fpubh.2019.00229] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/30/2019] [Indexed: 12/13/2022] Open
Abstract
Carbapenem-resistant, hypervirulent Klebsiella pneumoniae (CR-hvKP) has recently emerged as a significant threat to public health. In this study, 29 K. pneumoniae isolates were isolated from eight patients admitted to the intensive care unit (ICU) of a comprehensive teaching hospital located in China from March 2017 to January 2018. Clinical information of patients was the basis for the further analyses of the isolates including antimicrobial susceptibility tests, identification of antibiotic resistance and virulence gene determinants, multilocus sequence typing (MLST), XbaI-macrorestriction by pulsed-field gel electrophoresis (PFGE). Selected isolates representing distinct resistance profiles and virulence phenotypes were screened for hypervirulence in a Galleria mellonella larvae infection model. In the course of the outbreak, the overall mortality rate of patients was 100% (n = 8) attributed to complications arising from CR-hvKP infections. All isolates except one (28/29, 96.6%) were resistant to multiple antimicrobial agents, and harbored diverse resistance determinants that included the globally prevalent carbapenemase blaKPC−2. Most isolates had hypervirulent genotypes being positive for 19 virulence-associated genes, including iutA (25/29, 86.2%), rmpA (27/29, 93.1%), ybtA (27/29, 93.1%), entB (29/29, 100%), fimH (29/29, 100%), and mrkD (29/29, 100%). MLST revealed ST11 for the majority of isolates (26/29, 89,7%). Infection assays demonstrated high mortality in the Galleria mellonella model with the highest LD50 values for three isolates (<105 CFU/mL) demonstrating the degree of hypervirulence of these CR-hvKP isolates, and is discussed relative to previous outbreaks of CR-hvKP.
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Affiliation(s)
- Yajie Zhao
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Xiucai Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Von Vergel L Torres
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Haiyang Liu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Andrea Rocker
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Yizhi Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiawei Wang
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Lijiang Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenzi Bi
- School of Medicine, The Fourth Affiliated Hospital of Zhejiang University, Jinhua, China
| | - Jie Lin
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Richard A Strugnell
- Department of Microbiology and Immunology, The Peter Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia
| | - Siqin Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Trevor Lithgow
- Infection and Immunity Program, Department of Microbiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Tieli Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianming Cao
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
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Humphries RM, Yang S, Kim S, Muthusamy VR, Russell D, Trout AM, Zaroda T, Cheng QJ, Aldrovandi G, Uslan DZ, Hemarajata P, Rubin ZA. Duodenoscope-Related Outbreak of a Carbapenem-Resistant Klebsiella pneumoniae Identified Using Advanced Molecular Diagnostics. Clin Infect Dis 2019; 65:1159-1166. [PMID: 29579235 DOI: 10.1093/cid/cix527] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/22/2017] [Indexed: 01/15/2023] Open
Abstract
Background Carbapenem-resistant Klebsiella pneumoniae infections are increasingly prevalent in North American hospitals. We describe an outbreak of carbapenem-resistant K. pneumoniae containing the blaOXA-232 gene transmitted by contaminated duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedures. Methods An outbreak investigation was performed when 9 patients with blaOXA-232 carbapenem-resistant K. pneumoniae infections were identified at a tertiary care hospital. The investigation included 2 case-control studies, review of duodenoscope reprocessing procedures, and culture of devices. Carbapenem-resistant Enterobacteriacieae (CRE) isolates were evaluated with polymerase chain reaction analysis for carbapenemase genes, and isolates with the blaOXA-232 gene were subjected to whole-genome sequencing and chromosome single-nucleotide polymorphism analysis. On recognition of ERCP as a key risk factor for infection, targeted patient notification and CRE screening cultures were performed. Results Molecular testing ultimately identified 17 patients with blaOxa-232 carbapenem-resistant K. pneumoniae isolates, including 9 with infections, 7 asymptomatic carriers who had undergone ERCP, and 1 additional patient who had been hospitalized in India and was probably the initial carrier. Two case-control studies established a point-source outbreak associated with 2 specific duodenoscopes. A field investigation of the use, reprocessing, and storage of deuodenoscopes did not identify deviations from US Food and Drug Administration or manufacturer recommendations for reprocessing. Conclusions This outbreak demonstrated the previously underappreciated potential for duodenoscopes to transmit disease, even after undergoing high-level disinfection according to manufacturers' guidelines.
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Affiliation(s)
| | - Shuan Yang
- Department of Pathology and Laboratory Medicine and
| | - Stephen Kim
- Division of Digestive Diseases, David Geffen School of Medicine
| | | | - Dana Russell
- Clinical Epidemiology and Infection Prevention, and
| | | | | | - Quen J Cheng
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, and
| | - Grace Aldrovandi
- Children's Hospital of Los Angeles and Department of Pediatrics, Molecular Microbiology and Immunology, University of Southern California, Los Angeles
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30
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Woodworth MH, Hayden MK, Young VB, Kwon JH. The Role of Fecal Microbiota Transplantation in Reducing Intestinal Colonization With Antibiotic-Resistant Organisms: The Current Landscape and Future Directions. Open Forum Infect Dis 2019; 6:ofz288. [PMID: 31363779 PMCID: PMC6667716 DOI: 10.1093/ofid/ofz288] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/14/2019] [Indexed: 12/17/2022] Open
Abstract
The intestinal tract is a recognized reservoir of antibiotic-resistant organisms (ARO), and a potential target for strategies to reduce ARO colonization. Microbiome therapies such as fecal microbiota transplantation (FMT) have been established as an effective treatment for recurrent Clostridioides difficile infection and may be an effective approach for reducing intestinal ARO colonization. In this article, we review the current published literature on the role of FMT for eradication of intestinal ARO colonization, review the potential benefit and limitations of the use of FMT in this setting, and outline a research agenda for the future study of FMT for intestinal ARO colonization.
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Affiliation(s)
- Michael H Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College, Chicago, Illinois
| | - Vincent B Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Jennie H Kwon
- Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri
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31
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Carbapenemase producing Enterobacteriaceae in intensive care units in Ecuador: Results from a multicenter study. J Infect Public Health 2019; 13:80-88. [PMID: 31262670 DOI: 10.1016/j.jiph.2019.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/31/2019] [Accepted: 06/16/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Carbapenemase-producing Enterobacteriaceae (CPE) are of global concern due to the growing number of patients who acquire them and their association with high mortality rates. Although there are some reports of endemicity in developing countries, little is known about this microorganism, and Ecuador is not an exception. Subsequently, our objective was to clinically and molecularly characterize carbapenemase producing-Enterobacteriaceae in intensive care units (ICUs) in Guayaquil, Ecuador. METHODS To determine CPE colonization, we obtained perineal and inguinal swabs from patients admitted to seven intensive-care adult units in Guayaquil-Ecuador between February and April 2016. The Centers for Disease Control and Prevention (CDC) laboratory protocol and chromogenic agar were used to process the cultures. Polymerase chain reaction was used to confirm carbapenemase production. Genotypic analysis was performed by Multilocus Sequence Typing (MLST) and pulsed-field electrophoresis (PFEG). Demographic and clinical data were obtained from the electronic charts and patient's relatives. RESULTS Six hundred seventy-seven patients were included in the study, of whom 255 were colonized/infected by CPE. The CPE prevalence was 37.67%. Previous use of antimicrobials, use of invasive procedures and being burned at admission were associated with CPE. The most frequent infection was found after a surgical procedure. Klebsiella pneumoniae (n=249) was the predominant microorganism harbouring blaKPC, followed by Enterobactercloacae (n=8), Klebsiella aerogenes (n=4), Escherichia coli (n=4) and Klebsiella oxytoca (n=1). NDM was present in Proteus mirabilis. The strains were distributed in 19 sequence types (ST), and 10 were not reported previously in Ecuador. ST 258 was the sequence type isolated most frequently. CONCLUSION This study shows a high prevalence of CPE in ICUs, particularly K. pneumoniae blaKPC ST 258. The identification of KPC alleles may help to understand the routes of dissemination and control spread within ICUs in Guayaquil, Ecuador.
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Baron SA, Cassir N, Mékidèche T, Mlaga KD, Brouqui P, Rolain JM. Successful treatment and digestive decolonisation of a patient with osteitis caused by a carbapenemase-producing Klebsiella pneumoniae isolate harbouring both NDM-1 and OXA-48 enzymes. J Glob Antimicrob Resist 2019; 18:225-229. [PMID: 31201994 DOI: 10.1016/j.jgar.2019.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/20/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Carbapenem resistance in Klebsiella pneumoniae is an increasing problem worldwide and infections caused by this bacterium can be difficult to treat. This study reported the case of a patient from Romania, who was hospitalised in Bulgaria after an accident trauma. He then came to France for treatment of an osteitis caused by a Klebsiella pneumoniae carrying both blaNDM-1 and blaOXA-48. METHOD The resistome of this extremely drug-resistant bacterium was analysed both with phenotypic (large antibiotic susceptibility testing) and genomic methods (genome sequencing). The genetic environment of the two carbapenemases was studied. RESULTS Klebsiella pneumoniae ST307 carrying both a blaNDM-1 and blaOXA-48 gene was located on two different plasmids: Inc L/M and IncFII. The patient was successfully treated by a combination of intravenous colistin (9 MUI, then 4.5 MUI bd), intravenous fosfomycin (4g tds) and oral doxycycline (100mg bd) for 3 months. Faecal microbiota transplantation was successfully conducted for stool carriage. CONCLUSION The ST307 type is becoming endemic in hospital environments and is frequently associated with carbapenem resistance. Treatment of infection caused by multidrug-resistant bacteria is a clinical challenge, and the use of old antibiotics associated with screening and decolonisation of the reservoirs can be an efficient therapeutic alternative.
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Affiliation(s)
- Sophie Alexandra Baron
- Aix Marseille Université, IRD, MEPHI, Faculté de Médecine et de Pharmacie, Marseille, France; IHU Méditerranée Infection, Marseille, France; Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Nadim Cassir
- Aix Marseille Université, IRD, MEPHI, Faculté de Médecine et de Pharmacie, Marseille, France; IHU Méditerranée Infection, Marseille, France; Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Thibaut Mékidèche
- Aix Marseille Université, IRD, MEPHI, Faculté de Médecine et de Pharmacie, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - Kodjovi Dodji Mlaga
- Aix Marseille Université, IRD, MEPHI, Faculté de Médecine et de Pharmacie, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - Philippe Brouqui
- IHU Méditerranée Infection, Marseille, France; Assistance Publique des Hôpitaux de Marseille, Marseille, France; Aix Marseille Université, IRD, VITROME, Faculté de Médecine et de Pharmacie, Marseille, France
| | - Jean-Marc Rolain
- Aix Marseille Université, IRD, MEPHI, Faculté de Médecine et de Pharmacie, Marseille, France; IHU Méditerranée Infection, Marseille, France; Assistance Publique des Hôpitaux de Marseille, Marseille, France.
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Persisting intrahospital transmission of multidrug-resistant Klebsiella pneumoniae and challenges for infection control. Infect Control Hosp Epidemiol 2019; 40:904-909. [PMID: 31184564 DOI: 10.1017/ice.2019.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past several decades, the incidence of Klebsiella pneumoniae harboring resistance mechanisms against multiple antibiotic agents has increased on a global scale. We discuss reasons for ongoing transmission of multidrug-resistant K. pneumoniae in healthcare settings, which has resulted in the successful spread and establishment of this pathogen. It is now one of the most important causes of healthcare-associated infections worldwide.
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Fernandes MR, Sellera FP, Moura Q, Carvalho MPN, Rosato PN, Cerdeira L, Lincopan N. Zooanthroponotic Transmission of Drug-Resistant Pseudomonas aeruginosa, Brazil. Emerg Infect Dis 2019; 24:1160-1162. [PMID: 29774849 PMCID: PMC6004847 DOI: 10.3201/eid2406.180335] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We recovered VIM-2 carbapenemase-producing Pseudomonas aeruginosa isolates from an infected dog, its owner, and the domestic environment. Genomic investigation revealed household transmission of the high-risk hospital clone sequence type 233 in the human–animal–environment interface. Results suggest zooanthroponotic transmission of VIM-2–producing P. aeruginosa in the household following the patient's hospital discharge.
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Schweizer C, Bischoff P, Bender J, Kola A, Gastmeier P, Hummel M, Klefisch FR, Schoenrath F, Frühauf A, Pfeifer Y. Plasmid-Mediated Transmission of KPC-2 Carbapenemase in Enterobacteriaceae in Critically Ill Patients. Front Microbiol 2019; 10:276. [PMID: 30837980 PMCID: PMC6390000 DOI: 10.3389/fmicb.2019.00276] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/01/2019] [Indexed: 11/25/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) cause health care-associated infections worldwide, and they are of severe concern due to limited treatment options. We report an outbreak of KPC-2-producing CRE that was caused by horizontal transmission of a promiscuous plasmid across different genera of bacteria and hospitals in Germany. Eleven isolates (8 Citrobacter freundii, 2 Klebsiella oxytoca, and 1 Escherichia coli) were obtained from seven critically ill patients during the six months of the outbreak in 2016. One patient developed a CRE infection while the other six patients were CRE-colonized. Three patients died in the course of the hospital stay. Six of the seven patients carried the same C. freundii clone; one K. oxytoca clone was found in two patients, and one patient carried E. coli and C. freundii. Molecular analysis confirmed the presence of a conjugative, blaKPC-2-carrying 70 kb-IncN plasmid in C. freundii and E. coli and an 80 kb-IncN plasmid in K. oxytoca. All transconjugants harbored either the 70 or 80 kb plasmid with blaKPC-2, embedded within transposon variant Tn4401g. Whole genome sequencing and downstream bioinformatics analyses of all plasmid sequences showed an almost perfect match when compared to a blaKPC-2-carrying plasmid of a large outbreak in another German hospital two years earlier. Differences in plasmid sizes and open reading frames point to the presence of inserted mobile genetic elements. There are few outbreak reports worldwide on the transmission of blaKPC-2-carrying plasmids across different bacterial genera. Our data suggest a regional and supraregional spread of blaKPC-2-carrying IncN-plasmids harboring the Tn4401g isoform in Germany.
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Affiliation(s)
- Christian Schweizer
- Department of Infection Control/Internal Medicine, Paulinenkrankenhaus, Berlin, Germany.,Department of Infection Control, German Heart Center Berlin, Berlin, Germany
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jennifer Bender
- Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistances, Wernigerode, Germany
| | - Axel Kola
- Institute of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Manfred Hummel
- Department of Infection Control/Internal Medicine, Paulinenkrankenhaus, Berlin, Germany
| | - Frank-Rainer Klefisch
- Department of Infection Control/Internal Medicine, Paulinenkrankenhaus, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Partner Site Berlin, DZHK: German Centre for Cardiovascular Research, Berlin, Germany
| | - Andre Frühauf
- Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistances, Wernigerode, Germany
| | - Yvonne Pfeifer
- Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistances, Wernigerode, Germany
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NDM Metallo-β-Lactamases and Their Bacterial Producers in Health Care Settings. Clin Microbiol Rev 2019; 32:32/2/e00115-18. [PMID: 30700432 DOI: 10.1128/cmr.00115-18] [Citation(s) in RCA: 357] [Impact Index Per Article: 71.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
New Delhi metallo-β-lactamase (NDM) is a metallo-β-lactamase able to hydrolyze almost all β-lactams. Twenty-four NDM variants have been identified in >60 species of 11 bacterial families, and several variants have enhanced carbapenemase activity. Klebsiella pneumoniae and Escherichia coli are the predominant carriers of bla NDM, with certain sequence types (STs) (for K. pneumoniae, ST11, ST14, ST15, or ST147; for E. coli, ST167, ST410, or ST617) being the most prevalent. NDM-positive strains have been identified worldwide, with the highest prevalence in the Indian subcontinent, the Middle East, and the Balkans. Most bla NDM-carrying plasmids belong to limited replicon types (IncX3, IncFII, or IncC). Commonly used phenotypic tests cannot specifically identify NDM. Lateral flow immunoassays specifically detect NDM, and molecular approaches remain the reference methods for detecting bla NDM Polymyxins combined with other agents remain the mainstream options of antimicrobial treatment. Compounds able to inhibit NDM have been found, but none have been approved for clinical use. Outbreaks caused by NDM-positive strains have been reported worldwide, attributable to sources such as contaminated devices. Evidence-based guidelines on prevention and control of carbapenem-resistant Gram-negative bacteria are available, although none are specific for NDM-positive strains. NDM will remain a severe challenge in health care settings, and more studies on appropriate countermeasures are required.
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Shu LB, Lu Q, Sun RH, Lin LQ, Sun QL, Hu J, Zhou HW, Chan EWC, Chen S, Zhang R. Prevalence and phenotypic characterization of carbapenem-resistant Klebsiella pneumoniae strains recovered from sputum and fecal samples of ICU patients in Zhejiang Province, China. Infect Drug Resist 2018; 12:11-18. [PMID: 30588043 PMCID: PMC6302810 DOI: 10.2147/idr.s175823] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective To understand the prevalence and transmission of carbapenem-resistant Klebsiella pneumoniae (CRKP) in ICU patients in Zhejiang Province, China, and determined the genetic and phenotypic characteristics of these CRKP strains. Materials and Methods A total of 202 ICU patients from eight tertiary hospitals were recruited and 55 non-duplicate CRKP strains were collected during July and August in 2017. These strains were subjected to determination of MICs, carriage of carbapenemase genes and tet(A) variants, PFGE, MLST and virulence potential using G. mellonella larvae infection model. Results A total of 55 CRKP strains were recovered from 42 patients, representing a carriage rate of 20.8%. CRKP strains were recovered from both the intestinal and respiratory tract of 13 patients. Importantly, strains isolated from sputum and fecal samples often displayed identical PFGE profiles, suggesting that CRKP may also colonize the respiratory tract. The most dominant ST type of these CRKP strains was ST11, accounting for 78% (43/55) of the test strains. The majority of CRKP strains were resistant to multiple antibiotics, with the exception of tigecycline and ceftazidime/avibactam. Interestingly, 32 strains were found to harbor the tet(A) variant, which is known to confer reduced tigecycline susceptibility. Assessment of the virulence potential of these CRKP strains by string test showed that results were negative for 53 of the 55 test strains. However, further assessment of virulence potential using a G. mellonella larvae infection model showed that CRKP isolated from sputum consistently exhibited a higher virulence level than strains recovered from fecal samples. Conclusion CRKP is highly prevalent in ICU patients in Zhejiang Province with strains isolated from respiratory exhibiting higher virulence potential than those from GI tract. These data provide essential insight into development of new infection control measures to halt the transmission of CRKP in clinical settings.
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Affiliation(s)
- Ling-Bin Shu
- Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,
| | - Qun Lu
- Department of Hospital Infection Management, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ren-Hua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Le-Qing Lin
- Department of Intensive Care Unit, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Qiao-Ling Sun
- Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,
| | - Jie Hu
- Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,
| | - Hong-Wei Zhou
- Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,
| | - Edward Wai-Chi Chan
- Shenzhen Key Lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, China, .,State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,
| | - Sheng Chen
- Shenzhen Key Lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, China, .,State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,
| | - Rong Zhang
- Department of Clinical Laboratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,
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Saïdani N, Lagier JC, Cassir N, Million M, Baron S, Dubourg G, Eldin C, Kerbaj J, Valles C, Raoult D, Brouqui P. Faecal microbiota transplantation shortens the colonisation period and allows re-entry of patients carrying carbapenamase-producing bacteria into medical care facilities. Int J Antimicrob Agents 2018; 53:355-361. [PMID: 30472293 DOI: 10.1016/j.ijantimicag.2018.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/02/2018] [Accepted: 11/17/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colonisation with carbapenemase-producing Enterobacteriaceae or Acinetobacter (CPE/A) is associated with complex medical care requiring implementation of specific isolation policies and limitation of patient discharge to other medical facilities. Faecal microbiota transplantation (FMT) has been proposed in order to reduce the duration of gut colonisation. OBJECTIVES This study investigated whether a dedicated protocol of FMT could reduce the negativation time of CPE/A intestinal carriage in patients whose medical care has been delayed due to such colonisation. METHOD A matched case-control retrospective study between patients who received FMT treatment and those who did not among CPE/A-colonised patients addressed for initial clustering at the current institute. The study adjusted two controls per case based on sex, age, bacterial species, and carbapenemase type. The primary outcome was delay in negativation of rectal-swab cultures. RESULTS At day 14 post FMT, 8/10 (80%) treated patients were cleared for intestinal CPE/A carriage. In the control group, 2/20 (10%) had spontaneous clearance at day 14 after CPE/A diagnosis. Faecal microbiota transplantation led patients to reduce the delay in decolonisation (median 3 days post FMT for treated patients vs. 50.5 days after the first documentation of digestive carriage for control patients) and discharge from hospital (median 19.5 days post FMT for treated patients vs. 41 for control patients). CONCLUSION Faecal microbiota transplantation is a safe and time-saving procedure to discharge CPE/A-colonised patients from the hospital. A standardised protocol, including 5 days of antibiotic treatment, bowel cleansing and systematic indwelling devices removal, should improve protocol effectiveness.
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Affiliation(s)
- Nadia Saïdani
- AP-HM, IHU-Méditerranée Infection, Marseille, France
| | - Jean-Christophe Lagier
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France.
| | - Nadim Cassir
- AP-HM, IHU-Méditerranée Infection, Marseille, France
| | - Matthieu Million
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
| | - Sophie Baron
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, SSA, IHU-Méditerranée Infection, VITROME, Marseille, France
| | - Grégory Dubourg
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
| | - Carole Eldin
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
| | - Jad Kerbaj
- AP-HM, IHU-Méditerranée Infection, Marseille, France
| | - Camille Valles
- Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
| | - Didier Raoult
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
| | - Philippe Brouqui
- AP-HM, IHU-Méditerranée Infection, Marseille, France; Aix Marseille Université, IRD, IHU-Méditerranée Infection, MEPHI, Marseille, France
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Pirš M, Cerar Kišek T, Križan Hergouth V, Seme K, Mueller Premru M, Jeverica S, Logar M, Mrvič T, Žnidaršič B, Jordan Markočič O, Lejko Zupanc T. Successful control of the first OXA-48 and/or NDM carbapenemase-producing Klebsiella pneumoniae outbreak in Slovenia 2014-2016. J Hosp Infect 2018; 101:142-149. [PMID: 30399389 DOI: 10.1016/j.jhin.2018.10.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/30/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) occur only sporadically in Slovenia. AIM To describe the first Slovenian carbapenemase-producing (CP) Klebsiella pneumoniae and Escherichia coli outbreak which occurred at the tertiary teaching hospital University Medical Centre Ljubljana from October 2014 to April 2015. METHODS A CPE-positive case was defined as any patient infected or colonized with CPE. A strict definition of a contact patient was adopted. Measures to prevent cross-transmission included cohorting of all CPE carriers with strict contact precautions and assignment of dedicated healthcare workers, cohorting of all contact patients until obtaining the result of screening cultures, systematic rectal screening of contact patients, and tagging of all CPE-positive cases and their contacts. Educational campaigns on CPEs were implemented. Clinical specimens were processed using standard procedures. Pulsed-field gel electrophoresis (PFGE) was used to determine relatedness. Multi-locus sequence typing was performed on CP K. pneumoniae isolates that belonged to different pulsotypes. FINDINGS Before the outbreak was brought under control, 40 patients were colonized or infected with OXA-48 and/or New Delhi metallo-β-lactamase (NDM)-producing CPE; in 38 patients OXA-48 and/or NDM-producing K. pneumoniae was detected, in seven OXA-48 and/or NDM-producing E. coli was found together with K. pneumoniae, and in two patients only CP E. coli was isolated. The outbreak was oligoclonal with two major CP K. pneumoniae clusters belonging to ST437 and ST147 in epidemiologically linked patients. CONCLUSION Initial standard control measures failed to prevent the outbreak. Once the problem had been recognized, strict infection control measures and the education of healthcare workers contributed to the successful control of the outbreak.
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Affiliation(s)
- M Pirš
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - T Cerar Kišek
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - V Križan Hergouth
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - K Seme
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - M Mueller Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - S Jeverica
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - M Logar
- Infection Control Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - T Mrvič
- Infection Control Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - B Žnidaršič
- Infection Control Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - O Jordan Markočič
- Public Health Institute Ljubljana, Regional Unit Ljubljana, Ljubljana, Slovenia
| | - T Lejko Zupanc
- Infection Control Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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Clearance of carbapenemase-producing Enterobacteriaceae (CPE) carriage: a comparative study of NDM-1 and KPC CPE. Clin Microbiol Infect 2018; 24:1104.e5-1104.e8. [DOI: 10.1016/j.cmi.2018.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/17/2018] [Accepted: 05/20/2018] [Indexed: 11/20/2022]
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Szymanek-Majchrzak K, Mlynarczyk A, Kuthan R, Sawicka-Grzelak A, Majchrzak K, Kawecki D, Kosieradzki M, Durlik M, Deborska-Materkowska D, Paczek L, Mlynarczyk G. Significance of Screening Tests and the Incidence of New Delhi Metallo-beta-lactamase-Producing Gram-negative Bacilli in the Surgery and Transplantation Wards of a Warsaw Medical Center During the Period From April 2014 to May 2017. Transplant Proc 2018; 50:2159-2163. [PMID: 30177130 DOI: 10.1016/j.transproceed.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/16/2018] [Accepted: 04/06/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND The first New Delhi metallo-beta-lactamase (NDM)-producing bacteria were isolated in 2008 in the world, and in 2011 in Poland. Due to the high clonal diversity (17 types) of their blaNDM gene, encoded on (Tn125-like) mobile genetic elements, these strains usually exhibit resistance to nearly all available antibiotics, which is particularly dangerous for organ transplant recipients. PURPOSE To assess of the prevalence of Gram-negative NDM-positive bacilli in surgery/transplantation wards of a teaching hospital in Warsaw and to ascertain the significance of screening tests on the rates and nature of colonization. MATERIALS AND METHODS The evaluated strains were isolated from 30 patients (between April 2014 and May 2017). The species were identified with VITEK-MS, antibiotic susceptibility was determined with VITEK 2, disk-diffusion, and/or E-test methods, according to EUCAST guidelines. The presence of the blaNDM-1 gene was confirmed using the polymerase chain reaction technique. RESULTS AND CONCLUSIONS There were 77 blaNDM-1-positive Klebsiella pneumoniae strains isolated from 30 patients. Cultures from individual patients, mainly from rectal swabs (53.9%) and urine samples (39.8%), yielded 1-11 isolates. Fifteen patients were already colonized on admission, and the other 15 developed a symptomatic infection. In total, 24 (80%) patients were carriers, and their colonizations persisted for <1-20 months. Most isolates were susceptible only to colistin, gentamicin, amikacin, tigecycline, and/or sulfamethoxazole/trimethoprim. Gastrointestinal-tract-colonizing K pneumoniae are the main reservoir of the blaNDM-1 gene. Following the introduction of on-admission mandatory screening for carbapenem-resistant strains, the rates of NDM-producing K pneumoniae isolation increased (7.5-fold), while the rates of isolation from patients with symptomatic infections considerably decreased (2.8-fold).
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Affiliation(s)
- K Szymanek-Majchrzak
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland; Department of Medical Microbiology, The Infant Jesus Teaching Hospital, Warsaw, Poland.
| | - A Mlynarczyk
- Department of Medical Microbiology, The Infant Jesus Teaching Hospital, Warsaw, Poland
| | - R Kuthan
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - A Sawicka-Grzelak
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland; Department of Medical Microbiology, The Infant Jesus Teaching Hospital, Warsaw, Poland
| | - K Majchrzak
- Department of Prosthetic Dentistry, Medical University of Warsaw, Warsaw, Poland
| | - D Kawecki
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland
| | - M Kosieradzki
- Department of General and Transplantation Surgery, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Transplant Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - D Deborska-Materkowska
- Department of Transplant Medicine and Nephrology, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - L Paczek
- Department of Immunology, Transplantology and Internal Diseases, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - G Mlynarczyk
- Department of Medical Microbiology, Medical University of Warsaw, Warsaw, Poland; Department of Medical Microbiology, The Infant Jesus Teaching Hospital, Warsaw, Poland
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Davido B, Moussiegt A, Dinh A, Bouchand F, Matt M, Senard O, Deconinck L, Espinasse F, Lawrence C, Fortineau N, Saleh-Mghir A, Caballero S, Escaut L, Salomon J. Germs of thrones - spontaneous decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) in Western Europe: is this myth or reality? Antimicrob Resist Infect Control 2018; 7:100. [PMID: 30123500 PMCID: PMC6090624 DOI: 10.1186/s13756-018-0390-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/31/2018] [Indexed: 11/16/2022] Open
Abstract
Background In France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country. Material and methods Retrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions. Results We included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3). Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up. Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974). We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300). Conclusions Our study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.
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Affiliation(s)
- Benjamin Davido
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Aurore Moussiegt
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Aurélien Dinh
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Frédérique Bouchand
- 2Pharmacie Hospitalière, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Morgan Matt
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Olivia Senard
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Laurene Deconinck
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Florence Espinasse
- 3Hygiène Hospitalière, Hôpital Universitaire Ambroise-Paré, AP-HP, 92210 Boulogne-Billancourt, France
| | - Christine Lawrence
- 4Hygiène Hospitalière, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | - Nicolas Fortineau
- 5Laboratoire de Microbiologie, Hôpital Universitaire Kremlin-Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - Azzam Saleh-Mghir
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
| | | | - Lelia Escaut
- 7Maladies Infectieuses, Hôpital Universitaire Kremlin-Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
| | - Jérome Salomon
- 1Maladies infectieuses, Hôpital Universitaire Raymond-Poincaré, AP-HP, 92380 Garches, France
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Kim YK, Song SA, Lee JN, Oh M, Jo KM, Kim HJ, Lee JH, Park J, Jang HJ, Kim HK, Kiem S. Clinical factors predicting persistent carriage of Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacteriaceae among patients with known carriage. J Hosp Infect 2018; 99:405-412. [PMID: 29111353 DOI: 10.1016/j.jhin.2017.10.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Information on the natural duration of carbapenem-resistant Enterobacteriaceae (CRE) carriage and factors associated with persistence of carriage is limited. AIM To evaluate the clinical variables associated with persistent carriage of Klebsiella pneumoniae carbapenemase (KPC)-producing CRE. METHODS Data for patients admitted between June 2015 and December 2016 who were identified as KPC-producing CRE carriers by either rectal swabs or clinical cultures were reviewed retrospectively. Patients with follow-up culture data for three months after initial acquisition were included. Regression models were used to evaluate the clinical variables associated with persistence of carriage. FINDINGS Of the 100 eligible patients, 50 patients (50%) experienced spontaneous decolonization within three months. Among the 50 patients (50%) who remained culture positive after three months, 26 patients carried KPC-producing CRE after six months. Multi-variable analysis revealed that re-admission [adjusted odds ratio (aOR) 9.96; 95% confidence interval (CI) 1.13-87.98; P=0.039], duration of hospitalization (aOR 1.03; 95% CI 1.01-1.05; P=0.003), positive clinical culture (aOR 6.26; 95% CI 1.28-30.54; P=0.023) and carbapenem use (OR 9.15; 95% CI 1.85-45.27; P=0.007) were predictive for persistent carriage after six months. CONCLUSION The results suggest that patients with KPC-producing CRE in clinical specimens who are using carbapenem, particularly those with multiple and prolonged hospitalizations, are more likely to remain carriers after six months of initial acquisition. This information is useful for coordinating strategies for pre-emptive isolation by predicting the CRE carriage status appropriately, and ensuring active surveillance through risk factor stratification.
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Affiliation(s)
- Y K Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - S A Song
- Department of Laboratory Medicine, Inje University College of Medicine, Busan, Republic of Korea
| | - J N Lee
- Department of Laboratory Medicine, Inje University College of Medicine, Busan, Republic of Korea
| | - M Oh
- Department of Pharmacology, Clinical Trial Centre, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - K M Jo
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-J Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - J H Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - J Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-J Jang
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-K Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - S Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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Efficacy of sodium hypochlorite against multidrug-resistant Gram-negative bacteria. J Hosp Infect 2018; 100:e40-e46. [PMID: 30026008 DOI: 10.1016/j.jhin.2018.07.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/10/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Increased antimicrobial resistance has been observed among many bacteria leading to treatment failures in human and veterinary medicine. Disinfection is a prerequisite for infection control and prevention in healthcare settings. Chlorine compounds are cost-effective and accessible worldwide. AIM To determine the efficacy of sodium hypochlorite (NaOCl) against multidrug-resistant Gram-negative bacteria (MDR-GNB). METHODS Minimum inhibitory concentrations (MICs) were determined using broth macro-dilution. Bactericidal efficacy was measured by qualitative and quantitative suspension tests followed by practical tests without mechanical action on stainless steel carriers. The guidelines of the German Association for Applied Hygiene were followed. FINDINGS Results varied remarkably depending on the method. MICs were 0.1% or 0.2% NaOCl. Qualitative suspension tests revealed up to 500-fold lower bactericidal concentrations. Pseudomonas aeruginosa (P = 0.0025) was significantly less susceptible in these tests whereas quantitative suspension tests revealed no significant differences between strains (P > 0.05). Practical tests determined bactericidal concentrations of 0.8-0.32% NaOCl at 1 min of contact and even lower concentrations for longer contact times. At 1 min, five Klebsiella were significantly less susceptible (P = 0.0124), whereas the lower susceptibility of P. aeruginosa was not confirmed. Organic load inhibited bactericidal activity significantly, whereas contact time had a marginal effect. Differing test results underline that MIC determination and qualitative suspension tests may be insufficient approaches to evaluate bacterial susceptibility or resistance. CONCLUSION NaOCl efficiently reduced Pseudomonas aeruginosa, Acinetobacter spp., and Klebsiella spp., most notably in the absence of organic matter. Strain- and species-specific differences in susceptibility were noticed, but in general MDR-GNB revealed no higher tolerance to NaOCl.
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Lázaro-Perona F, Ramos JC, Sotillo A, Mingorance J, García-Rodríguez J, Ruiz-Carrascoso G, Paño-Pardo JR, Arribas JR, Herruzo R, Arnalich F. Intestinal persistence of a plasmid harbouring the OXA-48 carbapenemase gene after hospital discharge. J Hosp Infect 2018; 101:175-178. [PMID: 30017896 DOI: 10.1016/j.jhin.2018.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/05/2018] [Indexed: 11/17/2022]
Abstract
To study intestinal colonization by OXA-48-producing Klebsiella pneumoniae (KpO48) after hospital discharge, stool samples from 22 previously colonized subjects were collected. Time from discharge was 33-611 days, without readmissions. Eight subjects (36%) were identified as blaOXA-48 gene carriers. In all of them the hospital-acquired strain of KpO48 had been lost, and the gene was harboured by other strains of K. pneumoniae, Klebsiella oxytoca and/or Escherichia coli. Our findings show intestinal persistence for several months of a plasmid harbouring the OXA-48 carbapenemase gene in a significant proportion of individuals in the absence of antibiotic treatment.
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Affiliation(s)
- F Lázaro-Perona
- Servicio de Microbiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J C Ramos
- Unidad de Microbiología Clínica y Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain
| | - A Sotillo
- Servicio de Microbiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J Mingorance
- Servicio de Microbiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - J García-Rodríguez
- Servicio de Microbiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - G Ruiz-Carrascoso
- Servicio de Microbiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - J R Paño-Pardo
- Unidad de Microbiología Clínica y Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain
| | - J R Arribas
- Unidad de Microbiología Clínica y Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain
| | - R Herruzo
- Servicio de Medicina Preventiva, Hospital Universitario La Paz, Madrid, Spain
| | - F Arnalich
- Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, Spain
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Porreca AM, Sullivan KV, Gallagher JC. The Epidemiology, Evolution, and Treatment of KPC-Producing Organisms. Curr Infect Dis Rep 2018; 20:13. [PMID: 29730830 DOI: 10.1007/s11908-018-0617-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to investigate the evolution and epidemiology of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms and the current and future treatment options for infections caused by KPC-producing isolates. RECENT FINDINGS The emergence of resistance in Enterobacteriaceae producing carbapenemases globally has increased the challenges in treating infections caused by these organisms. One of the prominent mechanisms of resistance is the production of KPC enzymes. Infections caused by organisms producing KPCs have limited treatment options and are associated with poor clinical outcomes. The rapid rise of KPC-producing organisms necessitated the use of drugs with pharmacokinetic and toxicity limitations, including polymyxins, tigecycline, fosfomycin, and aminoglycosides. The availability of new beta-lactamase inhibitor combinations that are effective against KPC-producing organisms represent an advance in safety and efficacy. Several agents are currently being studied that have activity against KPC-producing organisms and appear to represent promising additions to our armamentarium. KPC-producing organisms cause infections with high morbidity and mortality. Limited treatment options are available, though new therapies have been developed. Pipeline agents are likely to have a place in therapy for the treatment of infections caused by KPC-producing isolates.
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Affiliation(s)
- Ann Marie Porreca
- Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, PA, USA
| | - Kaede V Sullivan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Jason C Gallagher
- Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, PA, USA.
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Singh R, de Groot PF, Geerlings SE, Hodiamont CJ, Belzer C, Berge IJMT, de Vos WM, Bemelman FJ, Nieuwdorp M. Fecal microbiota transplantation against intestinal colonization by extended spectrum beta-lactamase producing Enterobacteriaceae: a proof of principle study. BMC Res Notes 2018; 11:190. [PMID: 29566738 PMCID: PMC5863815 DOI: 10.1186/s13104-018-3293-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/13/2018] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Infections with multidrug-resistant microorganisms are associated with increased hospitalization, medication costs and mortality. Based on our fecal microbiota transplantation (FMT) experience for Clostridium difficile infection, we treated 15 patients carrying ESBL-producing Enterobacteriaceae (ESBL-EB) with FMT. Seven patients underwent a second FMT after 4 weeks when ESBL-EB remained, amounting to a total number of 22 transplants. The objective was decolonization of ESBL-EB. RESULTS Three out of fifteen (20%) patients were ESBL-negative at 1, 2 and 4 weeks after the first transplant, while six out of 15 (40%) were negative after the second transplant. Comparison of fecal microbiota at baseline and 4 weeks after FMT revealed restoration of microbial diversity after FMT and a microbial shift towards donor composition. Finally, we suggest several possible factors of response to therapy, such as donor-recipient microbiota match and number of FMTs. Therefore, FMT can be an effective treatment in patients carrying ESBL-EB. Response may be determined by microbiota composition and number of FMT procedures. Trial registration ISRCTN ISRCTN48328635 Registered 11 October 2017, retrospectively registered.
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Affiliation(s)
- Ramandeep Singh
- Renal Transplant Unit, Division of Nephrology, Academic Medical Centre, Room A3-273, PO box 22660, 1100 DD Amsterdam, The Netherlands
- Division of Infectious Diseases, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, Amsterdam, The Netherlands
| | - Pieter F. de Groot
- Division of Vascular Medicine, Academic Medical Centre, Room F4-256, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Suzanne E. Geerlings
- Division of Infectious Diseases, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, Amsterdam, The Netherlands
| | - Caspar J. Hodiamont
- Department of Medical Microbiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Clara Belzer
- Department of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Ineke J. M. ten Berge
- Renal Transplant Unit, Division of Nephrology, Academic Medical Centre, Room A3-273, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Willem M. de Vos
- Department of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Frederike J. Bemelman
- Renal Transplant Unit, Division of Nephrology, Academic Medical Centre, Room A3-273, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Division of Vascular Medicine, Academic Medical Centre, Room F4-256, PO box 22660, 1100 DD Amsterdam, The Netherlands
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
- ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
- Wallenberg Laboratory, Sahlgrenska Hospital, University of Gothenburg, Gothenburg, Sweden
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Kaiser T, Finstermeier K, Häntzsch M, Faucheux S, Kaase M, Eckmanns T, Bercker S, Kaisers UX, Lippmann N, Rodloff AC, Thiery J, Lübbert C. Stalking a lethal superbug by whole-genome sequencing and phylogenetics: Influence on unraveling a major hospital outbreak of carbapenem-resistant Klebsiella pneumoniae. Am J Infect Control 2018; 46:54-59. [PMID: 28935481 DOI: 10.1016/j.ajic.2017.07.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND From July 2010-April 2013, Leipzig University Hospital experienced the largest outbreak of a Klebsiella pneumoniae carbapenemase 2 (KPC-2)-producing Klebsiella pneumoniae (KPC-2-Kp) strain observed in Germany to date. After termination of the outbreak, we aimed to reconstruct transmission pathways by phylogenetics based on whole-genome sequencing (WGS). METHODS One hundred seventeen KPC-2-Kp isolates from 89 outbreak patients, 5 environmental KPC-2-Kp isolates, and 24 K pneumoniae strains not linked to the outbreak underwent WGS. Phylogenetic analysis was performed blinded to clinical data and based on the genomic reads. RESULTS A patient from Greece was confirmed as the source of the outbreak. Transmission pathways for 11 out of 89 patients (12.4%) were plausibly explained by descriptive epidemiology, applying strict definitions. Five of these and an additional 15 (ie, 20 out of 89 patients [22.5%]) were confirmed by phylogenetics. The rate of phylogenetically confirmed transmissions increased significantly from 8 out of 66 (12.1% for the time period before) to 12 out of 23 patients (52.2% for the time period after; P <.001) after implementation of systematic screening for KPC-2-Kp (33,623 screening investigations within 11 months). Using descriptive epidemiology, systematic screening showed no significant effect (7 out of 66 [10.6%] vs 4 out of 23 [17.4%] patients; P = .465). The phylogenetic analysis supported the assumption that a contaminated positioning pillow served as a reservoir for the persistence of KPC-2-Kp. CONCLUSIONS Effective phylogenetic identification of transmissions requires systematic microbiologic screening. Extensive screening and phylogenetic analysis based on WGS should be started as soon as possible in a bacterial outbreak situation.
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Findings from an outbreak of carbapenem-resistant Klebsiella pneumoniae emphasize the role of antibiotic treatment for cross transmission. Infection 2017; 46:103-112. [PMID: 29177610 DOI: 10.1007/s15010-017-1103-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE In January 2015, we noticed by rectal swab analyses that seven of 23 patients at an early rehabilitation ward had been colonized with carbapenem-resistant Klebsiella pneumoniae (CKP). Here, we describe risk factors for CKP acquisition. METHODS In the present study, the outbreak is described and risk factors for CKP acquisition are examined, e.g., antibiotic treatment. Microbiological analyses including corresponding results were examined to study when colonization with CKP occurred and whether patients had suffered from diarrhea. To examine whether spread of bacteria was clonal, multi-locus sequence typing as well as Xbal macrorestriction and pulsed-field gel electrophoresis was performed. The presence of carbapenmase was examined by PCR analysis. Through univariate analysis of risk factors in the small study sample, the role of antibiotic consumption, isolation procedures, patient's age, gender, and Barthel index on colonization was elucidated. RESULTS Clonal spread of the novel sequence type (ST)2255 was identified. Additionally, one patient was colonized with Escherichia coli and Serratia marcescens, both resistant to carbapenems, while a further patient carried another carbapenem-resistant E. coli strain. In all isolates, carbapenemase gene bla OXA-48 was found to be located on a conjugative plasmid (60 kb), suggesting in vivo transmission from CKP to E. coli and S. marcescens. Univariate tests indicated that antibiotic treatment was the only risk factor showing a significant association with being colonized by CKP. In addition, the likelihood of diarrhea appeared to be higher in this group. Antibiotic treatment was associated with CKP colonization, whereas patients´ age, gender, Barthel index at admission, and residence with a CKP-colonized roommate were not. Diarrhea also seemed to support to distribution of CKP. CONCLUSIONS In this small outbreak, antibiotic treatment seemed to be the predominant risk factor for monoclonal transmission of bla OXA-48 positive CKP.
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50
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Magiorakos AP, Burns K, Rodríguez Baño J, Borg M, Daikos G, Dumpis U, Lucet JC, Moro ML, Tacconelli E, Simonsen GS, Szilágyi E, Voss A, Weber JT. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control 2017; 6:113. [PMID: 29163939 PMCID: PMC5686856 DOI: 10.1186/s13756-017-0259-z] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/11/2017] [Indexed: 12/25/2022] Open
Abstract
Background Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E). The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. Methods The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings. Results Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE. Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. Conclusions Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here. This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources. Electronic supplementary material The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A P Magiorakos
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - K Burns
- Beaumont Hospital, Royal College of Surgeons in Ireland & Health Protection Surveillance Centre, Dublin, Ireland
| | - J Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - M Borg
- Departments of Infection Control & Sterile Services, Mater Dei Hospital, MSD2090, Msida, Malta
| | - G Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - U Dumpis
- Department of Infectious diseases and Infection Control. Pauls Stradins University Hospital, Riga, Latvia
| | - J C Lucet
- Infection Control Unit, Bichat Claude Bernard Hospital, AP-HP, Paris, France
| | - M L Moro
- Agenzia Sanitaria e Sociale Regione Emilia-Romagna, Bologna, Italy
| | - E Tacconelli
- Division of Infectious Diseases, Department Internal Medicine 1, DZIF Center, Tübingen University, Tübingen, Germany
| | - G Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, and UiT - The Arctic University of Norway, Tromsø, Norway
| | - E Szilágyi
- Department of Epidemiology and Hospital Hygiene, National Public Health and Medical Officer Service, Budapest, Hungary
| | - A Voss
- Department of Medical Microbiology, Radboud University Medical Centre and Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - J T Weber
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
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