Review of the epidemiological data regarding antimicrobial resistance in Gram-negative bacteria in Australia

Mortality, hospital length of stay, and recurrent bloodstream infections associated with extended-spectrum beta-lactamase-producing Escherichia coli in a low prevalence region: A 20-year population-based large cohort study

OBJECTIVES

This population-based study aimed to investigate the risk factors and effect of extended-spectrum beta-lactamase (ESBL) production on clinical outcomes in Escherichia coli bloodstream infection (BSI) patients.

METHODS

The study population was defined as patients aged ≥15 years with E. coli BSI in Queensland, Australia, from 2000 to 2019. Outcomes were defined as 30-day case fatality, hospital length of stay (LOS), and recurrent E. coli BSI.

RESULTS

A total of 27,796 E. coli BSIs were identified, of which 1112 (4.0%) were ESBL-producers. Patients with ESBL-Ec BSI were more frequently older, male, with comorbidity, recurrent E. coli BSI, and less likely with community-associated community-onset infections as compared to non-ESBL-Ec BSI patients. The standardized mortality rate of ESBL-Ec BSI increased 8-fold from 2000 to 2019 (1 to 8 per million residents) and case fatality was 12.8% (n = 142) at 30 days from positive blood culture. Patients with ESBL-Ec BSI were not at higher risk of 30-day case fatality (adjusted hazard ratio [HR] = 0.98, 95% CI: 0.83-1.17), but had higher risk of recurring episodes (adjusted subdistribution HR = 1.58, 95% CI: 1.29-1.92) and observed 14% longer LOS (adjusted incidence rate ratio = 1.14, 95% CI: 1.10-1.18) than non-ESBL-Ec BSI patients.

CONCLUSION

In this large patient cohort, ESBL-Ec BSI did not increase case fatality risk but observed higher hospital LOS and recurrent E. coli BSI than non-ESBL-Ec BSI. Clinical resources are warranted to account for the higher morbidity risk associated with ESBL production and incidence.

Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review

BACKGROUND

Antimicrobial resistance is one of the major public health challenges in Ethiopia. However, there is no comprehensive summary of existing AMR data in the country.

AIM

To determine the prevalence of antimicrobial resistance and its clinical implications in Ethiopia.

METHODS

A systematic literature search was performed on the PubMed/Medline database. Original studies on antimicrobial resistance conducted in Ethiopia between 1st January 2009 and 31st July 2019 were included. The outcome measure was the number of isolates resistant to antimicrobial agents in terms of specific pathogens, and disease condition. Data was calculated as total number of resistant isolates relative to the total number of isolates per specific pathogen and medication.

RESULTS

A total of 48,021 study participants enrolled from 131 original studies were included resulting in 15,845 isolates tested for antimicrobial resistance. The most common clinical sample sources were urine (28%), ear, nose, and throat discharge collectively (27%), and blood (21%). All the studies were cross-sectional and 83% were conducted in hospital settings. Among Gram-positive bacteria, the reported level of resistance to vancomycin ranged from 8% (Enterococcus species) to 20% (S. aureus). E. coli, K. pneumoniae and P. aeruginosa were the most common Gram-negative pathogens resistant to key antimicrobial agents described in the national standard treatment guideline and were associated with diverse clinical conditions: urinary tract infections, diarrhea, surgical site infections, pneumonia, ocular infections, and middle ear infections.

CONCLUSION

Overall, there is a high prevalence of antimicrobial resistance in Ethiopia. Empirical treatment of bacterial infections needs to be guided by up-to-date national guidelines considering local antimicrobial susceptibility patterns. Equipping diagnostic laboratories with culture and drug susceptibility testing facilities, and establishing a strong antimicrobial stewardship program should be high priorities.

Attributable Length of Stay, Mortality Risk, and Costs of Bacterial Health Care-Associated Infections in Australia: A Retrospective Case-cohort Study

Background

Unbiased estimates of the health and economic impacts of health care–associated infections (HAIs) are scarce and focus largely on patients with bloodstream infections (BSIs). We sought to estimate the hospital length of stay (LOS), mortality rate, and costs of HAIs and the differential effects on patients with an antimicrobial-resistant infection.

Methods

We conducted a multisite, retrospective case-cohort of all acute-care hospital admissions with a positive culture of 1 of the 5 organisms of interest (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, or Enterococcus faecium) from 1 January 2012 through 30 December 2016. Data linkage was used to generate a data set of statewide hospital admissions and pathology data. Patients with bloodstream, urinary, or respiratory tract infections were included in the analysis and matched to a sample of uninfected patients. We used multistate survival models to generate LOS, and logistic regression to derive mortality estimates.

Results

We matched 20 390 cases to 75 635 uninfected control patients. The overall incidence of infections due to the 5 studied organisms was 116.9 cases per 100 000 patient days, with E. coli urinary tract infections (UTIs) contributing the largest proportion (51 cases per 100 000 patient days). The impact of a UTI on LOS was moderate across the 5 studied pathogens. Resistance significantly increased LOS for patients with third-generation cephalosporin-resistant K. pneumoniae BSIs (extra 4.6 days) and methicillin-resistant S. aureus BSIs (extra 2.9 days). Consequently, the health-care costs of these infections were higher, compared to corresponding drug-sensitive strains.

Conclusions

The health burden remains highest for BSIs; however, UTIs and respiratory tract infections contributed most to the health-care system expenditure.

Gram-Negative Bacteria Isolates and Their Antibiotic-Resistance Patterns in Patients with Wound Infection in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

Antibiotic resistance (ABR) restricts the armamentarium of health-care providers against infectious diseases due to the emergence of multidrug resistance (MDR), especially in Gram-negative bacteria. This study aimed to determine pooled estimates of Gram-negative bacteria, their resistance profiles, and rates of MDR in patients with wound infection in Ethiopia.

METHODS

Electronic databases such as PubMed/MEDLINE, EMBASE, Science Direct, Web of Science, and Google Scholar were searched. Original articles, available online from 1988 to 2020, addressing the prevalence and resistance patterns of Gram-negative bacteria in patients with wound infection and written in English were screened. The data were extracted using a format prepared in Microsoft Excel and exported to STATA 14.0 for the outcome analyses.

RESULTS

The data of 15,647 wound samples, from 36 studies conducted in 5 regions of the country, were pooled. The overall pooled estimate of Gram-negative bacteria was 59% [95% CI: 52-65%, I2 = 96.41%, p < 0.001]. The pooled estimate of Escherichia colirecovered from isolates of 5205 wound samples was 17% [95% CI: 14-20%], followed by Pseudomonas aeruginosa, 11% [95% CI: 9-14%], Klebsiella pneumonia, 11% [95% CI: 9-13%], Proteus mirabilis, 8% [95% CI: 6-10%], Acinetobacter species, 4% [95% CI: 2-6%], Enterobacter species, 4% [95% CI: 3-5%], and Citrobacter species, 3% [95% CI: 2-4%]. Multidrug resistance prevalence estimates of E. coli, K. pneumonia, P. aeruginosa, P. mirabilis, Citrobacter species, Enterobacter species and Acinetobacter species were 76% [95% CI: 66-86%], 84% [95% CI: 78-91%], 66% [95% CI:43-88%], 83% [95% CI:75-91%], 87% [95% CI:78-96%], 68% [95% CI:50-87%] and 71% [95% CI:46-96%], respectively.

CONCLUSION

There was high resistance in Gram-negative bacteria from wound specimens to commonly used antibiotics in Ethiopia. The data warrant the need of regular epidemiological surveillance of antimicrobial resistance and implementation of an efficient infection control program.

A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes

The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

Bacteriology and Antimicrobial Resistance in Vanuatu: January 2017 to December 2019

Keywords: drug resistance; antimicrobial; public health surveillance; Pacific Islands; bacteriology; epidemiology.

In-Hospital Surgery as a Risk Factor for Onset of AmpC-Producing Escherichia coli Blood Stream Infections

There has been a progressive rise in the incidence of blood stream infections (BSI) caused by multidrug-resistant Gram-negative organisms (MDR GN), which cause increased morbidity and mortality. For this reason, recent studies have focused on risk factors of acquisition of carbapenemase-producing Enterobacteriaceae and extended-spectrum beta-lactamase producers. However, there is limited data on risk factors for BSI caused by AmpC-producing Enterobacteriaceae (AmpC EC), especially in low prevalence settings such as Australia. This study was performed to identify risk factors for acquisition of AmpC E. coli, using a retrospective matched case control design over a 3-year period. Patients with BSI caused by AmpC E. coli were matched with controls (third generation cephalosporin susceptible E. coli) by age and site of infection (n = 21). There was no significant difference in age, sex, clinical outcome, time to onset of BSI, recent antibiotic use (last 3 months), comorbidities (type 2 diabetes mellitus, renal failure) intensive care unit admission, underlying hematological condition, immunosuppressant use, APACHE II score, or any recent urological procedures (within last 3 months) between the two groups. On univariate analysis, the AmpC E. coli group were more likely to have had a surgical procedure in hospital and lived in a residential aged care facility. On multivariate logistic regression analysis, a recent surgical procedure was associated with the onset of AmpC E. coli BSI (Odd's Ratio (OR) 4.78, p = 0.034). We concluded that in a relatively low prevalence setting such as Australia, AmpC E. coli BSI is potentially associated with surgery performed in hospital due to previous antibiotic exposure and longer hospitalization.

Clinical management of drug-resistant bacteria in Australian hospitals: An online survey of doctors' opinions

BACKGROUND

To gain a better understanding of clinical practice for the treatment of common drug-resistant infections.

METHODS

A web-based anonymous survey was developed to gain a better understanding of clinical practice of patients infected with drug-resistant bloodstream infections (BSI). The survey instrument was a questionnaire requesting doctors to provide their opinion on the most likely choice of an antibiotic, dose and route of administration for patients infected with a drug-resistant Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa or Enterococcus faecium.

RESULTS

All of the survey participants (n = 28) were hospital-based doctors. Choice of therapy for drug-resistant E. coli and K. pneumoniae was uniform across survey participants. However, optimal treatment of ceftazidime-resistant P. aeruginosa and VRE was less clear.

CONCLUSION

The survey adds to the limited body of evidence in this clinical area and can be a useful tool for health economists in determining the additional cost of treating patients with drug-resistant infections.