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

Is It Time to Start Worrying? A Comprehensive Report on the Three-Year Prevalence of ESBL-Producing Bacteria and Their Trends in Antibiotic Resistance from the Largest University Hospital in Slovakia

BACKGROUND/OBJECTIVES

Over the past few decades, extended-spectrum β-lactamase (ESBL)-producing bacteria have become a great concern in healthcare systems worldwide, imposing large burdens by increasing antimicrobial resistance and patient morbidity. Given the high mortality rates and emergence of multidrug-resistant (MDR) strains, monitoring ESBL prevalence and resistance patterns is crucial. This study aimed to evaluate ESBL-producing Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae over three years, focusing on phenotypic distribution and resistance profiles.

METHODS

A total of 1599 ESBL-producing bacterial samples were collected and analysed. A panel of 20 antibiotics was tested to determine resistance traits. Data were recorded on phenotypical distribution, isolation types, changes in antibiotic resistance, and the relation of such changes to antibiotic consumption (defined daily dose) from clinical isolates.

RESULTS

Phenotypical analysis revealed the minimal presence of the Cefotaximase from Munich (CTX-M) phenotype in E. coli and K. pneumoniae, creating a distinct epidemiological profile compared to global patterns. Shifts in isolation trends, particularly in P. mirabilis, suggest an expected increase in associated-mortality-rate in the coming years. While resistance trends were not statistically significant, MDR and extensively drug-resistant (XDR) strains were identified across all three bacteria. Only meropenem showed consistent 100% efficacy against E. coli, with other antibiotics displaying only partial effectiveness.

CONCLUSIONS

These findings highlight the need for ongoing surveillance of ESBL-producing bacteria and underscore challenges in managing antibiotic resistance due to limited efficacy of last-resort treatments. The unique phenotypical distribution observed could impact local resistance management strategies in hospital settings in the coming years.

Fatal Acute Limb Ischemia Due to Catastrophic Late Endograft Infection and Adjacent Arterial Infection After Endovascular Aneurysm Repair - A Case Report

Introduction

We present a case of late endograft infection that progressed to the left iliac and femoral arteries, leading to left lower extremity gangrene, and the patient's death.

Case

A 65-year-old male with a history of endovascular abdominal aortic aneurysm repair (EVAR) developed left acute limb ischemia (Rutherford category III) and abdominal pain. A CT scan showed significant gas formation around the endograft and complete occlusion of the left distal iliac artery to the femoral arteries. Despite undergoing hip disarticulation and wound care, aortic endograft removal was not possible due to a lack of replacement grafts. Microbiological cultures from arterial pus and urine identified multiple antibiotic-resistant extended-spectrum beta-lactamases (ESBL) producing Escherichia coli. Histopathological analysis of the common femoral artery specimen indicated chronic medium-sized arteritis characterized by endothelial erosion, fibrotic myocytes in the tunica media, and fibrosis of the adventitial layer with inflammatory cell infiltration. The patient succumbed in the ICU 6 days later due to uncontrolled sepsis.

Discussion

Although the incidence of endograft infection after EVAR is low (20-75% morbidity and mortality), it poses significant risks. Sources are often hematogenous, stemming from urinary or respiratory tract infections, and infections extending to subsequent arteries are very rare; they could cause chronic arterial inflammation and, in the long term, may lead to thrombosis and limb ischemia. This case highlights a low-grade infection that emerged 3 months post-procedure. Diagnosis typically involves CT angiography to detect periaortic gas or fluid. Management of high-grade infections necessitates complete endograft removal and graft replacement with infection-resistant options.

Conclusion

Endograft infections after EVAR, while rare, can have severe outcomes. Early diagnosis based on symptoms and CT-Scan. In high-grade infections, endograft removal is the gold-standard therapy, with ongoing follow-up post-EVAR being essential for prevention.

One Health Approach to Study the Occurrence and Antimicrobial Resistance of Extended-Spectrum β-Lactamase- and Carbapenemase-Producing Escherichia coli and Klebsiella spp. in Urban Agriculture in Burkina Faso

Data on antimicrobial resistance in Burkina Faso's agricultural sector is still limited. This study assessed the occurrence of extended-spectrum β-lactamase-producing Escherichia coli (ESBL-Ec) and Klebsiella spp. (ESBL-K) in lettuce, environment, and gardeners' stools in market gardens in Ouagadougou, Burkina Faso. A total of 356 samples were collected from three vegetable gardens (76 lettuce, 76 soil, 62 manure, 63 irrigation water, and 79 human stools). The ESBL-selective medium was used for initial selection of ESBL-producing bacteria, and the isolates were further identified using biochemical tests. An antibiotic susceptibility test was performed using the disk diffusion method. The overall prevalence of ESBL-Ec and/or ESBL-K in the samples was 232/356 (65.2%). Of the lettuce samples, the prevalence of ESBL-Ec was 19/76 (25.0%) and ESBL-K 33/76 (43.4%). In the market gardens environment, the prevalence of ESBL-Ec was 32/201 (15.9%) and ESBL-K 124/201 (61.7%). In the gardeners' stools, the prevalence of ESBL-Ec was 42/79 (53.2%) and ESBL-K 24/79 (30.4%). Two ESBL-K isolates were found to produce NDM carbapenemase. Due to the high prevalence of ESBL-producing bacteria, which may also be carbapenemase producers, it is necessary to monitor pathogens in agricultural products with a "One Health" approach to limit and prevent infections in the population.

Assessment of Posttransplant Bacteremia Caused by Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacteria Among Kidney Transplant Recipients

BACKGROUND

Extended-spectrum beta-lactamase-producing gram-negative rods (ESBL-GNR) are a rising cause of bacteremia in kidney transplant recipients (KT). The study purpose was to examine patient mortality, allograft survival, estimated glomerular filtration rate (eGFR) at the end of 1 year, and readmission rates while looking at treatment strategies among KTs with ESBL-GNR and non-ESBL-GNR bacteremia at our institution.

METHODS

This study was a retrospective, cohort analysis of KTs with gram-negative bacteremia from January 1, 2020, to December 31, 2021. The primary outcome of the study was mortality. Patient outcomes were assessed for 365 days after positive blood cultures.

RESULTS

The study included 63 patients. Of these, 18 (29%) patients had bacteremia caused by an ESBL-GNR and 45 (71%) patients had bacteremia caused by a non-ESBL-GNR. Patient survival at 90 days was 94% in the ESBL-GNR group and 96% in the non-ESBL-GNR group. Ciprofloxacin was the most common antimicrobial therapy at discharge (68.9%) in the non-ESBL-GNR group whereas ertapenem was the most common in the ESBL-GNR group (44.5%). Median eGFR at discharge was 41 mL/min/1.73 m2 in the ESBL-GNR group and 48 mL/min/1.73 m2 in the non-ESBL-GNR group. Ninety-day readmission occurred in 9 (50%) ESBL-GNR patients and 14 (32%) non-ESBL-GNR patients. None of the above comparisons are statistically significant (p > 0.05). Eleven (61%) ESBL-GNR and 2 (4%) non-ESBL-GNR patients used outpatient parenteral antimicrobial therapy (p < 0.001).

CONCLUSIONS

Among KTs with ESBL-GNR bacteremia, no significant difference was detected in mortality or allograft function compared to non-ESBL-GNR bacteremia.

Effect of Different Approaches to Antimicrobial Therapy with Cefmetazole and Meropenem on the Time to Defervescence in Non-Severe Extended-Spectrum β-Lactamase-Producing Escherichia coli Bacteremia

Carbapenems are antimicrobial agents commonly used to treat extended-spectrum β-lactamase (ESBL)-producing bacteria. Although cefmetazole (CMZ) is considered effective for ESBL-producing Escherichia coli (ESBL-EC) bacteremia, previous studies showed its limitations, including the influence of the initial antimicrobial agent. Here, we examined the effects of different approaches to antimicrobial therapy with CMZ and meropenem (MEPM) on the time to defervescence in ESBL-EC bacteremia. Notably, the influence of previous antimicrobial agents was excluded. Inpatients with ESBL-EC detected in blood cultures between April 2018 and March 2023 were included and assigned to CMZ (n = 14), MEPM (n = 8), de-escalation to CMZ (dCMZ; n = 9), or escalation to MEPM (eMEPM; n = 11) groups. The median time to defervescence was 3.5, 1.0, 2.0, and 4.0 days in the CMZ, MEPM, dCMZ, and eMEPM groups, respectively, with no significant differences. Cox proportional hazards analysis showed a significant difference in the hazard ratio (95% confidence interval) of 0.378 (0.145-0.984) for the time to defervescence with CMZ versus MEPM (p = 0.046). The extent of a delayed time to defervescence is greater with early CMZ administration than with MEPM administration in patients with non-severe ESBL-EC bacteremia.