Multidrug-resistant bacteria in geriatric clinics, nursing homes, and ambulant care--prevalence and risk factors

Drivers of extended-spectrum β-lactamase (ESBL)- producing Enterobacterales colonization among residents of long-term care facilities: a European multicentre prospective cohort study

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-PE) are highly prevalent in long-term care (LTCF) settings. In order to estimate the acquisition rate of ESBL-producing Escherichia coli and Klebsiella pneumoniae in LTCF settings, and identify clinical and environmental risk factors, a multi-centre, prospective cohort study was conducted in six LTCFs in Germany, France, Spain and the Netherlands.

METHODS

Longitudinal screening of residents was performed over 32 weeks, collecting epidemiological and clinical data and environmental samples. The primary outcome was the rate of new acquisition of ESBL-PE among LTCF residents. Molecular epidemiology was studied using whole genome sequencing, and risk factor analysis was undertaken using logistic and Poisson regression models.

RESULTS

In total, 299 residents provided 1958 samples during follow-up. The prevalence of ESBL-PE colonization at baseline was 16.4%, and the incidence of acquisition was 0.79 per 1000 resident-days, both with high variability between LTCFs. Age ≥80 years, vascular disease and antibiotic consumption within the preceding year were risk factors for baseline colonization. Lack of hand sanitizers and a low nurse:resident ratio were associated with colonization. The presence of medical devices was associated with risk of acquisition. Vascular disease, hemiplegia, antibiotic consumption, and non-availability of private bathrooms were associated with carriage of multiple sequence types (STs). The prevalence of ESBL-PE among environmental samples was 2%, exclusively in LTCFs with high prevalence among residents. Genetic analysis showed a high prevalence of ST10 E. coli and ST405 K. pneumoniae at two study sites.

CONCLUSION

Infection prevention interventions, including availability of hand sanitizers, the number of nurses per resident, and antimicrobial stewardship, constitute important measures to control ESBL-PE in LTCFs. Genome-based surveillance could guide targeted interventions.

Risk factors for transmission of carbapenem-resistant Acinetobacter baumannii in outbreak situations: results of a case-control study

BACKGROUND

An increase in patients with multidrug-resistant organisms and associated outbreaks during the COVID-19 pandemic have been reported in various settings, including low-endemic settings. Here, we report three distinct carbapenem-resistant Acinetobacter baumannii (CRAB) outbreaks in five intensive care units of a university hospital in Berlin, Germany during the COVID-19 pandemic.

METHODS

A case-control study was conducted with the objective of identifying risk factors for CRAB acquisition in outbreak situations. Data utilized for the case-control study came from the investigation of three separate CRAB outbreaks during the COVID-19 pandemic (August 2020- March 2021). Cases were defined as outbreak patients with hospital-acquired CRAB. Controls did not have any CRAB positive microbiological findings and were hospitalized at the same ward and for a similar duration as the respective case. Control patients were matched retrospectively in a 2:1 ratio. Parameters routinely collected in the context of outbreak management and data obtained retrospectively specifically for the case-control study were included in the analysis. To analyze risk factors for CRAB acquisition, univariable and multivariable analyses to calculate odds ratios (OR) and 95% confidence intervals (CI) were performed using a conditional logistic regression model.

RESULTS

The outbreaks contained 26 cases with hospital-acquired CRAB in five different intensive care units. Two exposures were identified to be independent risk factors for nosocomial CRAB acquisition by the multivariable regression analysis: Sharing a patient room with a CRAB patient before availability of the microbiological result was associated with a more than tenfold increase in the risk of nosocomial CRAB acquisition (OR: 10.7, CI: 2.3-50.9), while undergoing bronchoscopy increased the risk more than six times (OR: 6.9, CI: 1.3-38.1).

CONCLUSIONS

The risk factors identified, sharing a patient room with a CRAB patient and undergoing bronchoscopy, could point to an underperformance of basic infection control measure, particularly hand hygiene compliance and handling of medical devices. Both findings reinforce the need for continued promotion of infection control measures. Given that the outbreaks occurred in the first year of the COVID-19 pandemic, our study serves as a reminder that a heightened focus on airborne precautions should not lead to a neglect of other transmission-based precautions.

Vancomycin-resistant enterococci (VRE) in hospital settings across European borders: a scoping review comparing the epidemiology in the Netherlands and Germany

The rising prevalence of vancomycin-resistant enterococci (VRE) is a matter of concern in hospital settings across Europe without a distinct geographical pattern. In this scoping review, we compared the epidemiology of vancomycin-resistant Enterococcus spp. in hospitals in the Netherlands and Germany, between 1991 and 2022. We searched PubMed and summarized the national antibiotic resistance surveillance data of the two countries. We included 46 studies and summarized national surveillance data from the NethMap in the Netherlands, the National Antimicrobial Resistance Surveillance database in Germany, and the EARS-Net data. In total, 12 studies were conducted in hospitals in the Netherlands, 32 were conducted in German hospitals, and an additional two studies were conducted in a cross-border setting. The most significant difference between the two countries was that studies in Germany showed an increasing trend in the prevalence of VRE in hospitals, and no such trend was observed in studies in the Netherlands. Furthermore, in both Dutch and German hospitals, it has been revealed that the molecular epidemiology of VREfm has shifted from a predominance of vanA towards vanB over the years. According to national surveillance reports, vancomycin resistance in Enterococcus faecium clinical isolates fluctuates below 1% in Dutch hospitals, whereas it follows an increasing trend in German hospitals (above 20%), as supported by individual studies. This review demonstrates that VRE is more frequently encountered in German than in Dutch hospitals and discusses the underlying factors for the difference in VRE occurrence in these two neighboring countries by comparing differences in healthcare systems, infection prevention control (IPC) guidelines, and antibiotic use in the Netherlands and Germany.

The global prevalence of methicillin-resistant Staphylococcus aureus colonization in residents of elderly care centers: a systematic review and meta-analysis

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a difficult to treat infection, particularly in residents of elderly care centers (ECCs). Despite the substantial burden of MRSA, an inadequate number of studies have analyzed MRSA prevalence in ECCs.

OBJECTIVES

We conducted a worldwide systematic review and meta-analysis on the prevalence and risk factors of MRSA in ECCs.

METHODS

We searched MEDLINE/PubMed, EMBASE, Web of Science, and Scopus databases and the gray literature sources for all studies published between January 1980 and December 2022 on the prevalence of MRSA in ECCs. A random-effects model was utilized to estimate pooled prevalence rates at 95% confidence intervals (CI). Moreover, the data were analyzed based on World Health Organization-defined regions, income, and human development index levels.

RESULTS

In total, 119 studies, including 164,717 participants from 29 countries, were found eligible for meta-analysis. The pooled global prevalence of MRSA was 14.69% (95% CI 12.39-17.15%; 16,793/164,717). Male gender [prevalence ratio (PR) = 1.55; 95% CI 1.47-1.64], previous MRSA infection (PR = 3.71; 95% CI 3.44-4.01), prior use of antibiotics (PR = 1.97; 95% CI 1.83-2.12), hospitalized within the previous year (PR = 1.32; 95% CI 1.20-1.45), have had any wound (PR = 2.38; 95% CI 2.23-2.55), have used urinary catheter (PR = 2.24; 95% CI 2.06-2.43), have used any medical device (PR = 1.78; 95% CI 1.66-1.91), and those with diabetes (PR = 1.55; CI 1.43-1.67) were more likely to be colonized by MRSA than other patients.

CONCLUSION

Screening programs and preventive measures should target MRSA in ECCs due to the high global prevalence rates.

Whole Genome Sequencing and Molecular Analysis of Carbapenemase-Producing Escherichia coli from Intestinal Carriage in Elderly Inpatients

The spread of carbapenemase-producing (CP) Enterobacterales is currently a worldwide concern, especially in the elderly. Twelve CP-E. coli isolated from rectal swabs of colonized inpatients aged ≥65 years from four hospitals in two Italian cities (Milan and Rome) were analyzed by whole genome sequencing (WGS) to obtain multi-locus sequence typing (MLST), identification of carbapenemase-encoding genes, resistome, plasmid content, and virulence genes. MLST analysis showed the presence of 10 unrelated lineages: ST410 (three isolates from three different hospitals in two cities) and ST12, ST38, ST69, ST95, ST131, ST189, ST648, ST1288, and ST1598 (one isolate each). Most isolates (9/12, 75%) contained a serine-β-lactamase gene (5 bla_KPC-3, 2 bla_KPC-2, and 2 bla_OXA-181), while three isolates harbored a metallo-β-lactamase gene (two bla_NDM-5 and one bla_VIM-1). In most CP-E. coli, the presence of more than one plasmid was observed, with the predominance of IncF. Several virulence genes were detected. All isolates contained genes enhancing the bacterial fitness, such as gad and terC, and all isolates but one, fimH, encoding type 1 fimbriae. In conclusion, CP-E. coli clones colonizing elderly patients showed heterogeneous genetic backgrounds. We recommend strict surveillance to monitor and prevent the spread of successful, high-risk clones in healthcare settings.

The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature

BACKGROUND

Despite the adoption of strict infection prevention and control measures, many hospitals have reported outbreaks of multidrug-resistant organisms (MDRO) during the Coronavirus 2019 (COVID-19) pandemic. Following an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in our institution, we sought to systematically analyse characteristics of MDRO outbreaks in times of COVID-19, focussing on contributing factors and specific challenges in controlling these outbreaks.

METHODS

We describe results of our own CRAB outbreak investigation and performed a systematic literature review for MDRO (including Candida auris) outbreaks which occurred during the COVID-19 pandemic (between December 2019 and March 2021). Search terms were related to pathogens/resistance mechanisms AND COVID-19. We summarized outbreak characteristics in a narrative synthesis and contrasted contributing factors with implemented control measures.

RESULTS

The CRAB outbreak occurred in our intensive care units between September and December 2020 and comprised 10 patients (thereof seven with COVID-19) within two distinct genetic clusters (both ST2 carrying OXA-23). Both clusters presumably originated from COVID-19 patients transferred from the Balkans. Including our outbreak, we identified 17 reports, mostly caused by Candida auris (n = 6) or CRAB (n = 5), with an overall patient mortality of 35% (68/193). All outbreaks involved intensive care settings. Non-adherence to personal protective equipment (PPE) or hand hygiene (n = 11), PPE shortage (n = 8) and high antibiotic use (n = 8) were most commonly reported as contributing factors, followed by environmental contamination (n = 7), prolonged critical illness (n = 7) and lack of trained HCW (n = 7). Implemented measures mainly focussed on PPE/hand hygiene audits (n = 9), environmental cleaning/disinfection (n = 9) and enhanced patient screening (n = 8). Comparing potentially modifiable risk factors and control measures, we found the largest discrepancies in the areas of PPE shortage (risk factor in 8 studies, addressed in 2 studies) and patient overcrowding (risk factor in 5 studies, addressed in 0 studies).

CONCLUSIONS

Reported MDRO outbreaks during the COVID-19 pandemic were most often caused by CRAB (including our outbreak) and C. auris. Inadequate PPE/hand hygiene adherence, PPE shortage, and high antibiotic use were the most commonly reported potentially modifiable factors contributing to the outbreaks. These findings should be considered for the prevention of MDRO outbreaks during future COVID-19 waves.

Novel insights into pivotal risk factors for rectal carriage of extended-spectrum-β-lactamase-producing enterobacterales within the general population in Lower Saxony, Germany

AIMS

To estimate the prevalence of extended-spectrum-β-lactamase (ESBL)-producing enterobacterales (ESBL-E) carriage in the general population of Lower Saxony, Germany, and to identify risk factors for being colonized.

METHODS AND RESULTS

Participants were recruited through local press and information events. Detection of ESBL-E by culture was conducted using ESBL-selective chromagar plates containing third-generation cephalosporins. Identification of pathogens was performed using matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF)_technology on Vitek mass spectrometry. Antibiotic susceptibility testing was conducted by microdilution (Vitek II) and an ESBL confirmation assay was carried out using a combination disk test. Of 527 randomly collected stool samples from healthy volunteers, 5.5% were tested positive for ESBL-E. Post-stratification for age and gender yielded a similar population estimate (5.9%). People traveling abroad and taking antibiotics had the greatest rectal ESBL-E carriage.

CONCLUSIONS

Potential risk factors (eg, working in healthcare facilities, recent inpatient stay) did not attribute to rectal ESBL-E carriage as other factors (eg, travelling, taking antibiotics). Rectal ESBL-E carriage within the general population seems to be high.

SIGNIFICANCE AND IMPACT OF THE STUDY

The known risk factors for carriage with MDRO might not be fully applicable to ESBL-E and require further examination in order to develop effective strategies for the prevention of ESBL-E dissemination within the general population.

Rectal Colonization by Drug Resistant Bacteria in Nursing Home Residents in Crete, Greece

(1) Background: In an area with a high prevalence of multi-drug resistant Gram-negative bacteria (MDR-GNB), we investigated the colonization of nursing home residents by such organisms. (2) Methods: A point prevalence study was performed in six nursing homes of the Heraklion area on the island of Crete. A rectal swab was taken and cultured from each participant, while additional risk factors such as recent hospitalization or antimicrobial usage were recorded and evaluated. (3) Results: A total of 137 nursing home residents were included in the study. Their mean age was 82.1 years and 19.7% were males. In total, cultures yielded 255 GNB; E. coli, K. pneumoniae and P. aeruginosa were the most common. Among the microorganisms cultured, 17.6% had the extended-spectrum beta-lactamase phenotype, while 18% were MDR. A statistically significant association was found between recent antimicrobial use and colonization by MDR-GNB; (4) Conclusions: Colonization by MDR-GNB was found to be highly prevalent in nursing home residents. Recent antimicrobial use was associated with MDR-GNB carriage.

Prevalence and risks factors associated with ESBL-producing faecal carriage in a single long-term-care facility in Spain: emergence of CTX-M-24- and CTX-M-27-producing Escherichia coli ST131-H30R

OBJECTIVES

To address the faecal carriage prevalence of antibiotic-multiresistant bacteria and associated risk factors in a public long-term care facility (LTCF).

METHODS

A prospective study in a single government-funded LTCF of 300 residents in Ciudad Real, Spain. Residents' clinical and demographic data were collected, as well as recent antibiotic consumption in the institution. Each participant contributed a rectal swab, which was plated on selective and differential-selective media. Colonies were identified by MALDI-TOF and ESBL production was confirmed by the double-disc synergy method, with characterization of the molecular mechanism by PCR. Isolates were typed by PFGE and submitted for ST131 screening by PCR.

RESULTS

Faecal carriage of ESBL-producing Enterobacterales was detected in 58 (31%) of 187 participants and previous infection by MDR bacteria was identified as a risk factor. The genes characterized were: blaCTX-M-15 (40.6%); blaCTX-M-14 (28.8%); blaCTX-M-27 (13.5%); and blaCTX-M-24 (10.1%). Some 56.4% of the isolates were grouped into the E. coli ST131 clone; 70.9% of these corresponded to the O25b serotype, 51.6% of them to Clade C1 (H30) and 12.9% to Clade C2 (H30Rx). Clade C1 isolates were mostly C1-M27, whereas the C2 sublineage was mainly related to the production of CTX-M-15. ST131-CTX-M-24 isolates (n = 6) corresponded to Clade A with serotype O16.

CONCLUSIONS

A high prevalence of ESBL-producing Enterobacterales faecal carriage has been detected in a single LTCF, highlighting the emergence of ST131 Clade A-M24 and Clade C1-M27 lineages.

Prevalence and Risk Factors for Multidrug-Resistant Organisms Colonization in Long-Term Care Facilities Around the World: A Review

Elderly people confined to chronic care facilities face an increased risk of acquiring infections by multidrug-resistant organisms (MDROs). This review presents the current knowledge of the prevalence and risk factors for colonization by MDROs in long-term care facilities (LTCF), thereby providing a useful reference to establish objectives for implementing successful antimicrobial stewardship programs (ASPs). We searched in PubMed and Scopus for studies examining the prevalence of MDROs and/or risk factors for the acquisition of MDROs in LTCF. One hundred and thirty-four studies published from 1987 to 2020 were included. The prevalence of MDROs in LTCF varies between the different continents, where Asia reported the highest prevalence of extended-spectrum ß-lactamase (ESBL) Enterobacterales (71.6%), carbapenem resistant (CR) Enterobacterales (6.9%) and methicillin-resistant Staphylococcus aureus (MRSA) (25.6%) and North America the highest prevalence to MDR Pseudomonas aeruginosa (5.4%), MDR Acinetobacter baumannii (15.0%), vancomycin-resistant Enterococcus spp. (VRE) (4.0%), and Clostridioides difficile (26.1%). Furthermore, MDRO prevalence has experienced changes over time, with increases in MDR P. aeruginosa and extended spectrum ß-lactamase producing Enterobacterales observed starting in 2015 and decreases of CR Enterobacterales, MDR A. baumannii, VRE, MRSA and C. difficile. Several risk factors have been found, such as male sex, chronic wounds, the use of medical devices, and previous antibiotic use. The last of these aspects represents one of the most important modifiable factors for reducing colonization with MDROs through implementing ASPs in LTCF.

The Prevalence of Virulence Determinants and Antibiotic Resistance Patterns in Methicillin-Resistant Staphylococcus aureus in a Nursing Home in Poland

Nursing homes (NH) contribute to the regional spread of methicillin-resistant Staphylococcus aureus (MRSA). Moreover, residents are vulnerable to the colonization and subsequent infection of MRSA etiology. We aimed at investigating the molecular and phenotypic characteristics of 21 MRSA collected from the residents and personnel in an NH (Lublin, Poland) during 2018. All MRSA were screened for 20 genes encoding virulence determinants (sea-see, eta, etb, tst, lukS-F-PV, eno, cna, ebpS, fib, bbp, fnbA, fnbB, icaADBC) and for resistance to 18 antimicrobials. To establish the relatedness and clonal complexes of MRSA in NH we applied multiple-locus variable-number tandem-repeat fingerprinting (MLVF), pulse field gel electrophoresis (PFGE), multilocus sequence typing (MLST) and staphylococcal cassette chromosome mec (SCCmec) typing. We identified four sequence types (ST) among two clonal complexes (CC): ST (CC22) known as EMRSA-15 as well as three novel STs—ST6295 (CC8), ST6293 (CC8) and ST6294. All tested MRSA were negative for sec, eta, etb, lukS-F-PV, bbp and ebpS genes. The most prevalent gene encoding toxin was sed (52.4%; n = 11/21), and adhesins were eno and fnbA (100%). Only 9.5% (n = 2/21) of MRSA were classified as multidrug-resistant. The emergence of novel MRSA with a unique virulence and the presence of epidemic clone EMRSA-15 creates challenges for controlling the spread of MRSA in NH.

Antibiotic Resistance in Pseudomonas spp. Through the Urban Water Cycle

Selection and dissemination of resistant bacteria and antibiotic resistance genes (ARGs) require a deeper understanding since antibiotics are permanently released to the environment. The objective of this paper was to evaluate the phenotypic resistance of 499 isolates of Pseudomonas spp. from urban water sources, and the prevalence of 20 ARGs within those isolates. Resistance to penicillins, cephalosporins, carbapenems, quinolones, macrolides, and tetracyclines was mainly observed in the hospital effluent, municipal wastewater and river water downstream the city. Resistant strains were frequently identified as P. aeruginosa and P. putida. P. aeruginosa isolates were mostly resistant to cefepime, ceftazidime, imipenem, and gentamycin, while P. putida strains were especially resistant to piperacillin-tazobactam. ARGs such as bla_TEM-1, bla_SHV-1, bla_PER-1, bla_AmpC, bla_VIM-1, PstS, qnrA, qnrB, ermB, tetA, tetB and tetC have been detected. The bla_AmpC gene was found in P. aeruginosa, while bla_TEM-1 and bla_PER-1 genes were found in P. putida. Class 1 integron integrase gene was found in 6.81% of the Pseudomonas isolates.

COVID-19 in long-term care facilities in Frankfurt am Main, Germany: incidence, case reports, and lessons learned

Abstract: As of August 30, 2020, the World Health Organisation (WHO) reported 24,822,800 COVID-19 infections world wide. Severe disease and deaths occur especially in older people with chronic illnesses. Residents of nursing homes are considered to be the most vulnerable group. In this paper, the experiences with COVID-19 in nursing homes in Frankfurt will be presented and discussed.

Materials and methods: Based on the data of the statutory reporting obligation, the reported COVID-19 cases are presented and incidences are calculated in different age groups and among residents of nursing homes. Outbreaks in various homes are described in detail based on the documentation from the public health department.

Results: By August 28, 2020, 2,665 COVID-19 infections were reported in Frankfurt am Main (incidence 351/100,000 inhabitants), including 116 (4.3%) residents of nursing homes (2,416/100,000 residents). Almost half (39%) of all deaths in Frankfurt (n=69; incidence 9.1/100,000) were among nursing home residents (n=27; incidence 558/100,000 nursing home residents), with 22 of them in just one long-term care facility (LTCF). Compared to previous years, the mortality rate in nursing homes did not increase in the first half of 2020. In one home, 75% of residents tested positive for SARS-CoV-2 and 25% died; in two other homes, 6.7% and 14.1% of the residents became infected, and the mortality rate was 0.5% and 1%, resp. In the other 42 homes in the city (3,906 beds), the infection rate remained below 1% and the death rate was 0.1%.

Discussion: In many countries, 30–70% of all deaths occur among nursing home residents, including Frankfurt (39%). An increase in overall mortality compared to previous years was not observed in Frankfurt as a whole or in the nursing homes in the city specifically. Due to the measures taken (monitoring of residents and staff, nursing care in protective clothing, prohibition or restriction of visits, physical distancing, isolation of infected people and quarantining of contact persons), only individual cases of COVID-19 illnesses occurred in nursing home residents in most homes and the outbreaks in the three homes could be stopped. We do not recommend regular nontargeted testing in nursing homes, but rather vigilance and the implementation of good hygiene as well as immediate targeted testing if COVID-19 is suspected in residents or staff. In order to mitigate the considerable negative effects of these measures on the residents, a good balance should be sought between infection prevention and the goal of ensuring self-determination and the residents’ quality of life.

Extended-Spectrum β-Lactamase- and Carbapenemase-Producing Enterobacterales Intestinal Carriage Among Outpatients: Microbiological and Epidemiological Differences Between Private Dwelling Residents and Nursing Home Residents

The aim of this work was to assess the prevalence of carbapenemase-producing and extended-spectrum β-lactamase-producing Enterobacterales (ESBLPE) intestinal carriage among private dwelling residents (PDR) and nursing home residents (NHR) from the catchment area of Hospital Verge de la Cinta (Tortosa. North-Eastern Spain), and to depict clinicoepidemiological features of colonized individuals. Prevalence of ESBLPE carriage amid 762 PDR (0-94 years) who had feces collected for routine culture was 7.3% and 31% among 71 NHR (68-98 years) screened upon hospital admission. The mean age of colonized and noncolonized subjects was 30 and 32.8 years in PDR (p = 0.58) and 85 and 87 years in NHR (p = 0.32). The predominant ESBLPE was CTX-M-15-producing Escherichia coli (42.8% in PDR and 68.2% in NHR [25% and 86.7% belonging to O25b-ST131 clone; p < 0.0001]), followed by CTX-M-9-group- and SHV-producing E. coli and by CTX-M-15-producing Klebsiella pneumoniae. Overall, 72.7% of ESBLPE were multidrug resistant and 46.2% carried transferable quinolone determinants. Institutionalization in a nursing home was a risk factor for ESBLPE and extended-spectrum β-lactamase (ESBL)-producing O25b-ST131 E. coli carriage in individuals over 67 years (odds ratio 7.7 and 14.1). Previous antibiotic use and skin ulcers were significantly associated with ESBLPE carriage in NHR. Age <25 years in PDR and amoxicillin/clavulanate exposure in NHR protected against ESBL-producing O25b-ST131 E. coli colonization. Only two PDR, with known risk factors, bore OXA-48-producing isolates. These results highlight the role of nonhospitalized intestinal carriers, particularly NHR, as ESBLPE reservoirs and the preponderance of CTX-M-15, mainly linked to O25b-ST131 clone, as well as the emergence of carbapenemase-producing Enterobacterales carriers.

Complication Rates After TRUS Guided Transrectal Systematic and MRI-Targeted Prostate Biopsies in a High-Risk Region for Antibiotic Resistances

Introduction: There is still an ongoing debate whether a transrectal ultrasound (TRUS) approach for prostate biopsies is associated with higher (infectious) complications rates compared to transperineal biopsies. This is especially of great interests in settings with elevated frequencies of multidrug resistant organisms (MDRO).

Materials and Methods: Between 01/2018 and 05/2019 230 patients underwent a TRUS-guided prostate biopsy at the department of Urology at University Hospital Frankfurt. Patients were followed up within the clinical routine that was not conducted earlier than 6 weeks after the biopsy. Among 230 biopsies, 180 patients took part in the follow-up. No patients were excluded. Patients were analyzed retrospectively regarding complications, infections and underlying infectious agents or needed interventions.

Results: Of all patients with follow up, 84 patients underwent a systematic biopsy (SB) and 96 a targeted biopsy (TB) after MRI of the prostate with additional SB. 74.8% of the patients were biopsy-naïve. The most frequent objective complications (classified by Clavien-Dindo) lasting longer than one day after biopsy were hematuria (17.9%, n = 32), hematospermia (13.9%, n = 25), rectal bleeding (2.8%, n = 5), and pain (2.2%, n = 4). Besides a known high MDRO prevalence in the Rhine-Main region, only one patient (0.6%) developed fever after biopsy. One patient each (0.6%) consulted a physician due to urinary retention, rectal bleeding or gross hematuria. There were no significant differences in complications seen between SB and SB + TB patients. The rate of patients who consulted a physician was significantly higher for patients with one or more prior biopsies compared to biopsy-naïve patients.

Conclusion: Complications after transrectal prostate biopsies are rare and often self-limiting. Infections were seen in <1% of all patients, regardless of an elevated local prevalence of MDROs. Severe complications (Clavien-Dindo ≥ IIIa) were only seen in 3 (1.7%) of the patients. Repeated biopsy is associated with higher complication rates in general.

Epidemiology of Vancomycin-Resistant Enterococcus faecium and Enterococcus faecalis Colonization in Nursing Facilities

BACKGROUND

Vancomycin-resistant Enterococcus faecium and Enterococcus faecalis frequently colonize nursing facility (NF) residents, creating opportunities for vancomycin-resistant Enterococcus (VRE) transmission and dissemination of mobile genetic elements conferring antimicrobial resistance. Most VRE studies do not speciate; our study addresses this lack and compares the epidemiology of E faecium and E faecalis.

METHODS

We enrolled 651 newly admitted patients from 6 different NFs and collected swabs from several body sites at enrollment, 14 days, 30 days, and monthly thereafter for up to 6 months. The VRE were speciated using a duplex polymerase chain reaction. We used multinomial logistic regression models to compare risk factors associated with colonization of E faecium and E faecalis.

RESULTS

Overall, 40.7% were colonized with E faecium, E faecalis, or both. At enrollment, more participants were colonized with E faecium (17.8%) than E faecalis (8.4%); 3.2% carried both species. Enterococcus faecium was carried twice as long as E faecalis (69 days and 32 days, respectively), but incidence rates were similar (E faecium, 3.9/1000 person-days vs E faecalis, 4.1/1000 person-days). Length of stay did not differ by species among incident cases. Residents who used antibiotics within the past 30 days had a greater incidence of both E faecium (odds ratio [OR] = 2.89; 95% confidence interval [CI], 1.82-4.60) and E faecalis (OR = 1.80; 95% CI, 1.16-2.80); device use was most strongly associated with the incidence of E faecium colonization (OR = 2.01; 95% CI, 1.15-3.50).

CONCLUSIONS

Recent increases in vancomycin-resistant E faecium prevalence may reflect increased device use and longer duration of carriage.

Active surveillance at the time of hospital admission for multidrug-resistant microorganisms among patients who had recently been hospitalized at health care facilities

BACKGROUND

This study aimed to investigate the epidemiology of multidrug-resistant microorganism (MDRO) carriage at hospital admission and to identify risk factors for MDRO influx into hospital settings.

METHODS

This cohort study was conducted at a 1,051-bed university-affiliated hospital in the Republic of Korea between July 1 and December 31, 2017. Active surveillance for MDRO carriage was performed within 48 hours of hospitalization in all adult patients who had prior hospitalization within the preceding 3 months.

RESULTS

During the study, 575 patients were admitted with a hospitalization history within 3 months. Active surveillance at hospital admission was performed in 192 eligible patients. Thirty-three (17.2%) patients with MDRO carriage were identified from active surveillance. In the multivariate logistic regression analysis, prior exposure to antibiotics within 90 days, hospitalization for ≥60 days before admission, cognitive dysfunction, percutaneous drainage, and underlying pulmonary diseases were identified as independent risk factors for MDRO influx.

CONCLUSIONS

Our findings suggest a significant prevalence of MDRO acquisition at acute care hospital admission in patients who had been recently hospitalized. To control the spread of MDRO, collaborations among health care institutions and targeted screening at hospital admission according to patient risk factors are warranted.

Occupational Infection Risk with Multidrug-Resistant Organisms in Health Personnel-A Systematic Review

The increase in multi-drug-resistant organisms (MDROs) in the last years has become a public health problem. MDROs are partially responsible for numerous nosocomial infections, extended hospital stays, high costs, and high mortality. In addition to methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), Gram-negative bacteria are also a key area of focus. The knowledge of MDROs among the medical staff in the occupational context is limited, with the exception of MRSA. Therefore, a systematic review was carried out to determine the occupational risk for employees posed by MDROs. The search included studies from the year 2000 onwards among personnel who had contact with MDROs. A total of 22 primarily cross-sectional studies in hospital or geriatric care settings were found, with large differences regarding number of participants, examination method, inclusion of a control group, and study quality. The most frequently examined pathogens were extended-spectrum ß-lactamase (ESBL)-producing bacteria with a prevalence of 2.6-48.5%, VRE (0-9.6%), and MRSA (0.9-14.5%). There are only few qualitatively good studies available on MDROs' risk infection for employees in the health service. Any comparison of the results was limited by data heterogeneity. More research is required to describe the occupational risk of infection with MDROs.

Prevalence of multidrug-resistant organisms in nursing homes in Belgium in 2015

Objectives

Following two studies conducted in 2005 and 2011, a third prevalence survey of multidrug-resistant microorganisms (MDRO) was organised in Belgian nursing homes (NHs) using a similar methodology. The aim was to measure the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase producing Enterobacteriaceae (ESBLE) and carbapenemase-producing Enterobacteriaceae (CPE) in NH residents. Risk factors for MDRO carriage were also explored.

Methods

Up to 51 randomly selected residents per NH were screened for MDRO carriage by trained local nurses between June and October 2015. Rectal swabs were cultured for ESBLE, CPE and VRE, while pooled samples of nose, throat and perineum and chronic wound swabs were obtained for culture of MRSA. Antimicrobial susceptibility testing, molecular detection of resistance genes and strain genotyping were performed. Significant risk factors for MDRO colonization MDRO was determined by univariate and multivariable analysis.

Results

Overall, 1447 residents from 29 NHs were enrolled. The mean weighted prevalence of ESBLE and MRSA colonization was 11.3% and 9.0%, respectively. Co-colonization occurred in 1.8% of the residents. VRE and CPE carriage were identified in only one resident each. Impaired mobility and recent treatment with fluoroquinolones or with combinations of sulphonamides and trimethoprim were identified as risk factors for ESBLE carriage, while for MRSA these were previous MRSA carriage/infection, a stay in several different hospital wards during the past year, and a recent treatment with nitrofuran derivatives. Current antacid use was a predictor for both ESBL and MRSA carriage.

Conclusions

In line with the evolution of MRSA and ESBL colonization/infection in hospitals, a decline in MRSA carriage and an increase in ESBLE prevalence was seen in Belgian NHs between 2005 and 2015. These results show that a systemic approach, including surveillance and enhancement of infection control and antimicrobial stewardship programs is needed in both acute and chronic care facilities.

Factors Associated with Vancomycin-Resistant Enterococcus Colonization in Patients Transferred to Emergency Departments in Korea

BACKGROUND

Vancomycin-resistant enterococci (VRE) infections have become a major healthcare-associated pathogen problem worldwide. Nosocomial VRE infections could be effectively controlled by screening patients at high risk of harboring VRE and thereby lowering the influx of VRE into healthcare centers. In this study, we evaluated factors associated with VRE colonization in patients transferred to emergency departments, to detect patients at risk for VRE carriage.

METHODS

This study was conducted in the emergency department of a medical college-affiliated hospital in Korea. Every patient transferred to the emergency department and admitted to the hospital from January to December 2016 was screened for VRE using rectal cultures. In this cross-sectional study, the dependent variable was VRE colonization and the independent variables were demographic and clinical factors of the patients and factors related to the transferring hospital. Patients were divided into two groups, VRE and non-VRE, and previously collected patient data were analyzed. Then we performed logistic regression analyses of characteristics that differed significantly between groups.

RESULTS

Out of 650 patients, 106 (16.3%) had positive VRE culture results. Significant variables in the logistic analysis were transfer from geriatric long-term care hospital (adjusted odds ration [aOR]: 8.017; 95% confidence interval [CI]: 1.378-46.651), hospital days (4-7 days; aOR: 7.246; 95% CI: 3.229-16.261), duration of antimicrobial exposure (1-3 days; aOR: 1.976; 95% CI: 1.137-3.436), and age (aOR: 1.025; 95% CI: 1.007-1.043).

CONCLUSION

VRE colonization in patients transferred to the emergency department is associated primarily with factors related to the transferred hospitals rather than demographic and clinical characteristics.

Ceftriaxone treatment of complicated urinary tract infections as a risk factor for enterococcal re-infection and prolonged hospitalization: A 6-year retrospective study

A frequent complication during hospital stay of patients with urinary tract infections (UTIs) is a re-infection of the urinary tract after the initial improvement. In this study, we investigated the impact of two empirical antibiotic therapies on the outcomes of complicated bacterial UTIs. We retrospectively evaluated 325 adult patients hospitalized during 6 years period with a diagnosis of complicated bacterial UTIs. The patients were classified into two groups according to the antibiotic therapy: ceftriaxone- and co-amoxiclav+gentamicin-treated group. Clinical data were collected from the patient records into a designed form. Output data included information on the treatment outcome, length of stay (LOS), development of complications, and cause of re-infections. The patients treated with ceftriaxone had significantly longer LOS (p = 0.012), as well as higher occurrence of complications (p = 0.023) and urinary tract re-infections (p < 0.001), compared to co-amoxiclav+gentamicin-treated group. No significant difference was observed in the treatment outcome between the two groups (p = 0.137). The most common complication in both investigated groups were re-infections of the urinary tract, and Enterococcus spp. was detected as the cause of re-infections only in patients from ceftriaxone-treated group (40/69 patients). Out of the 40 ceftriaxone-treated patients with enterococcal urinary tract re-infections, 35 patients had one or more chronic diseases and 29 patients had urinary catheter inserted. Ceftriaxone therapy should be considered carefully in patients with complicated UTIs due to the possibility of enterococcal re-infection and consequent prolonged hospital stay.

Prevalence and risk factors of MRSA colonisations: a cross-sectional study among personnel in outpatient care settings in Hamburg, Germany

OBJECTIVES

Healthcare workers frequently come into contact with infected individuals and are at a greater risk of infection than the general population due to their occupation. Multidrug-resistant organisms (MDROs) also pose a significant challenge for personnel and medical facilities. Currently, little is known about the occupational risk of methicillin-resistant Staphylococcus aureus (MRSA) in outpatient care settings. Therefore, a cross-sectional study was conducted in Hamburg to investigate MRSA colonisation among outpatient nursing staff.

METHODS

MRSA screening with nasal swabs was carried out, the known risk factors for colonisation were determined and information on infection control was inquired. Where tests were positive, a control swab was taken; if this confirmed a positive result, decolonisation was offered. A molecular biological examination of the MRSA samples was performed. The occupational MRSA exposure and risk factors were compared with the situation for personnel in inpatient geriatric care.

RESULTS

A total of 39 outpatient services participated in the study and 579 employees were tested. The MRSA prevalence was 1.2% in all and 1.7% in nursing staff. Most of the employees that tested positive had close or known contact with MRSA patients. Health personnel frequently reported personal protective measures and their application. Compared with inpatient care staff, outpatient staff were older and had worked in their profession for a longer time.

CONCLUSION

This study marks the first time that data has been made available on the occupational MRSA risk of outpatient care personnel in Hamburg. The MRSA prevalence is low and provides a good basis for describing the MRSA risk of occupational exposure by health personnel in outpatient care.

Antimicrobial-Resistant Klebsiella pneumoniae Carriage and Infection in Specialized Geriatric Care Wards Linked to Acquisition in the Referring Hospital

Background

Klebsiella pneumoniae is a leading cause of extended-spectrum β-lactamase (ESBL)-producing hospital-associated infections, for which elderly patients are at increased risk.

Methods

We conducted a 1-year prospective cohort study, in which a third of patients admitted to 2 geriatric wards in a specialized hospital were recruited and screened for carriage of K. pneumoniae by microbiological culture. Clinical isolates were monitored via the hospital laboratory. Colonizing and clinical isolates were subjected to whole-genome sequencing and antimicrobial susceptibility testing.

Results

K. pneumoniae throat carriage prevalence was 4.1%, rectal carriage 10.8%, and ESBL carriage 1.7%, and the incidence of K. pneumoniae infection was 1.2%. The isolates were diverse, and most patients were colonized or infected with a unique phylogenetic lineage, with no evidence of transmission in the wards. ESBL strains carried blaCTX-M-15 and belonged to clones associated with hospital-acquired ESBL infections in other countries (sequence type [ST] 29, ST323, and ST340). One also carried the carbapenemase blaIMP-26. Genomic and epidemiological data provided evidence that ESBL strains were acquired in the referring hospital. Nanopore sequencing also identified strain-to-strain transmission of a blaCTX-M-15 FIBK/FIIK plasmid in the referring hospital.

Conclusions

The data suggest the major source of K. pneumoniae was the patient's own gut microbiome, but ESBL strains were acquired in the referring hospital. This highlights the importance of the wider hospital network to understanding K. pneumoniae risk and infection prevention. Rectal screening for ESBL organisms on admission to geriatric wards could help inform patient management and infection control in such facilities.

Naso- and oropharyngeal bacterial carriage in nursing home residents: Impact of multimorbidity and functional impairment

OBJECTIVE

From April 2013 to February 2014 we performed a multicentre prospective cross-sectional study in 541 German nursing home residents. We determined pharyngeal carriage of Streptococcus pneumoniae (primary objective) and other bacteria (secondary objective) in naso- and oropharyngeal swabs by culture-based standard procedures and explored the influence of multimorbidity and functional status on bacterial carriage.

METHODS

Socio-demographic data, vaccination status, multimorbidity, nutrition and functional status defined by Comprehensive Geriatric Assessment were evaluated. We estimated carriage rates with 95% confidence intervals (CI) and explored potential risk factors by logistic regression analysis.

RESULTS

Pneumococcal post-serotyping carriage rate was 0.8% (95%CI 0.2-1.9%; 4/526). Serotyping revealed serotypes 4, 7F, 23B and 23F and S. pseudopneumoniae in two other cases. Odds of carriage were higher in men (Odds ratio OR 5.3 (95%CI 0.9-29.4)), in malnourished residents (OR 4.6 (0.8-25.7)), residents living in shared rooms (OR 3.0 (0.5-16.5)) or having contact with schoolchildren (OR 2.0 (0.2-17.6)). The most frequent pathogen was Staphylococcus aureus (prevalence 29.5% (25.6-33.6%)) with meticillin-resistant Staphylococcus aureus prevalence of 1.1%. Gram-negative bacteria (GNB) were found in 22.5% (19.0-26.3%) with a prevalence of extended-spectrum beta lactamase (ESBL) producing bacteria of 0.8%. Odds of S. aureus carriage were higher for immobility (OR 1.84 (1.15-2.93)) and cognitive impairment (OR 1.54 (0.98-2.40)). Odds of GNB carriage were higher in residents with more severe comorbidity (OR 1.13 (1.00-1.28)) and malnutrition (OR 1.54 (0.81-2.91)).

CONCLUSIONS

Given the observed data, at least long-term carriage of S. pneumoniae in nursing home residents seems to be rare and rather unlikely to cause nursing home acquired pneumonia. The low rate of colonization with multi drug resistant (MDR) bacteria confirms that nursing home residency is not a risk factor for MDR pneumonia in Germany. For individual risk assessment in this susceptible population, immobility and malnutrition should be considered as signs of functional impairment as well as comorbidity.

Low prevalence of colonization with multidrug-resistant gram-negative bacteria in long-term care facilities in Graz, Austria

BACKGROUND

Residents in long-term care facilities (LTCFs) are increasingly found to be an important reservoir of multidrug-resistant gram-negative (MRGN) bacteria.

AIMS

We aimed to determine colonization by MRGN bacteria over 6 months in LTCFs and geriatric wards in Graz, Austria, and to evaluate risk factors for such colonization.

METHODS

During August 2015, we conducted a point-prevalence survey at LTCFs and geriatric wards of the Geriatric Health Centers of the City of Graz. Inguinal and perianal swabs were taken from 137 patients and screened for MRGN using standard procedures. Six months after the initial investigation all colonized patients were sampled again and use of antibiotics, hospital admissions, and mortality was registered. Genetic relatedness of MRGN bacteria was evaluated.

RESULTS

We detected 12 patients harboring MRGN isolates (prevalence, 8.7%). Overall inguinal colonization was 5.1%. After 6 months, only 2 out of 12 patients were still colonized. Presence of a urinary catheter was associated with a higher risk of MRGN colonization (odds ratio [OR], 17.5; 95% CI, 1.6-192). Chronic wounds and gastrostomy were also risk factors of MRGN colonization (OR, 10.7; 95% CI, 1.6-69.3 and OR, 18.3; 95% CI, 2.4-139.4, respectively). There was no difference in mortality between colonized and noncolonized patients.

CONCLUSIONS

Prevalence of colonization with MRGN bacteria was low in patients in LTCFs and geriatric wards in Graz, Austria.

Newly identified risk factors for MRSA carriage in The Netherlands

OBJECTIVES

To elucidate new risk factors for MRSA carriers without known risk factors (MRSA of unknown origin; MUO). These MUO carriers are neither pre-emptively screened nor isolated as normally dictated by the Dutch Search & Destroy policy, thus resulting in policy failure.

METHODS

We performed a prospective case control study to determine risk factors for MUO acquisition/carriage (Dutch Trial Register: NTR2041). Cases were MUO carriers reported by participating medical microbiological laboratories to the RIVM from September 1st 2011 until September 1st 2013. Controls were randomly selected from the community during this period.

RESULTS

Significant risk factors for MUO in logistic multivariate analysis were antibiotic use in the last twelve months, aOR 8.1 (5.6-11.7), screened as contact in a contact tracing but not detected as a MRSA carrier at that time, aOR 4.3 (2.1-8.8), having at least one foreign parent, aOR 2.4 (1.4-3.9) and receiving ambulatory care, aOR 2.3 (1.4-3.7). Our found risk factors explained 83% of the MUO carriage.

CONCLUSIONS

Identifying new risk factors for MRSA carriers remains crucial for countries that apply a targeted screening approach as a Search and Destroy policy or as vertical infection prevention measure.

Understanding institutional stakeholders' perspectives on multidrug-resistant bacterial organism at the end of life: a qualitative study

Background

Information lacks about institutional stakeholders’ perspectives on management approaches of multidrug-resistant bacterial organism in end-of-life situations. The term “institutional stakeholder” includes persons in leading positions with responsibility in hospitals’ multidrug-resistant bacterial organism management. They have great influence on how strategies on multidrug-resistant bacterial organism management approaches in institutions of the public health system are designed. This study targeted institutional stakeholders’ individual perspectives on multidrug-resistant bacterial organism colonization or infection and isolation measures at the end of life.

Methods

Between March and December 2014, institutional stakeholders of two study centers, a German palliative care unit and a geriatric ward, were queried in semistructured interviews. Interviews were audiotaped, transcribed verbatim, and analyzed qualitatively with the aid of the software MAXQDA for qualitative data analysis using principles of Grounded Theory. In addition, two external stakeholders were interviewed to enrich data.

Results

Key issues addressed by institutional stakeholders (N=18) were the relevance of multidrug-resistant bacterial organism in palliative and geriatric care, contradictions between hygiene principles and patients’ and family caregivers’ needs and divergence from standards, frame conditions, and reflections on standardization of multidrug-resistant bacterial organism end-of-life care procedures. Results show that institutional stakeholders face a dilemma between their responsibility in protecting third persons and ensuring patients’ quality of life. Until further empirical evidence establishes a clear multidrug-resistant bacterial organism management approach in end-of-life care, stakeholders suggest a case-based approach.

Conclusion

The institutional stakeholders’ perspectives and their suggestion of a case-based approach advance the development process of a patient-, family-, staff-, and institutional-centered approach of how to deal with multidrug-resistant bacterial organism-positive patients in end-of-life care. Institutional stakeholders play an important role in the implementation of recommendations following this approach.

Longitudinal genomic surveillance of multidrug-resistant Escherichia coli carriage in a long-term care facility in the United Kingdom

BACKGROUND

Residents of long-term care facilities (LTCF) may have high carriage rates of multidrug-resistant pathogens, but are not currently included in surveillance programmes for antimicrobial resistance or healthcare-associated infections. Here, we describe the value derived from a longitudinal epidemiological and genomic surveillance study of drug-resistant Escherichia coli in a LTCF in the United Kingdom (UK).

METHODS

Forty-five of 90 (50%) residents were recruited and followed for six months in 2014. Participants were screened weekly for carriage of extended-spectrum beta-lactamase (ESBL) producing E. coli. Participants positive for ESBL E. coli were also screened for ESBL-negative E. coli. Phenotypic antibiotic susceptibility of E. coli was determined using the Vitek2 instrument and isolates were sequenced on an Illumina HiSeq2000 instrument. Information was collected on episodes of clinical infection and antibiotic consumption.

RESULTS

Seventeen of 45 participants (38%) carried ESBL E. coli. Twenty-three of the 45 participants (51%) had 63 documented episodes of clinical infection treated with antibiotics. Treatment with antibiotics was associated with higher risk of carrying ESBL E. coli. ESBL E. coli was mainly sequence type (ST)131 (16/17, 94%). Non-ESBL E. coli from these 17 cases was more genetically diverse, but ST131 was found in eight (47%) cases. Whole-genome analysis of 297 ST131 E. coli from the 17 cases demonstrated highly related strains from six participants, indicating acquisition from a common source or person-to-person transmission. Five participants carried highly related strains of both ESBL-positive and ESBL-negative ST131. Genome-based comparison of ST131 isolates from the LTCF study participants with ST131 associated with bloodstream infection at a nearby acute hospital and in hospitals across England revealed sharing of highly related lineages between the LTCF and a local hospital.

CONCLUSIONS

This study demonstrates the power of genomic surveillance to detect multidrug-resistant pathogens and confirm their connectivity within a healthcare network.

Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis

BACKGROUND

Multidrug-resistant gram-negative bacteria (MDR-GNB) are associated with an increasing proportion of infections among nursing home (NH) residents. The objective of this systematic review and meta-analysis was to critically review evidence of the prevalence of MDR-GNB among NH residents.

METHODS

Following Meta-Analysis of Observational Studies in Epidemiology guidelines, a systematic review of literature for the years 2005-2016 using multiple databases was conducted. Study quality, appraised by 2 reviewers, used Downs and Black risk of bias criteria. Studies reporting prevalence of MDR-GNB colonization were pooled using a random effects meta-analysis model. Heterogeneity was assessed using Cochran Q and I² statistics.

RESULTS

Of 327 articles, 12 met the criteria for review; of these, 8 met the criteria for meta-analysis. Escherichia coli accounted for the largest proportion of isolates. Reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%. Pooled prevalence for MDR-GNB colonization, representing data from 2,720 NH residents, was 27% (95% confidence interval, 15.2%-44.1%) with heterogeneity (Q = 405.6; P = .01; I² = 98.3). Two studies reported MDR-GNB infection rates of 10.9% and 62.7%.

CONCLUSION

Our findings suggest a high prevalence of MDR-GNB colonization among NH residents, emphasizing the need to enhance policies for infection control and prevention (ICP) in NHs.

Colonization by multidrug-resistant organisms in long-term care facilities in Italy: a point-prevalence study

OBJECTIVES

To determine prevalence and risk factors for colonization by multidrug-resistant organisms (MDROs) in long-term care facility (LTCF) residents in Italy. Genotypes of MDRO isolates were investigated.

METHODS

A point-prevalence study was conducted at 12 LTCFs located in four Italian cities (2 February to 14 March 2015). Rectal swabs, faeces and nasal/auxiliary swabs were cultured for extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacteriaceae, Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) respectively. Antimicrobial susceptibility testing, detection of ESBL and/or carbapenemase genes and molecular typing of MDROs were performed. Risk factors for colonization were determined by univariate and multivariate analysis.

RESULTS

A total of 489 LTCF residents aged ≥65 years were enrolled. The prevalence of colonization by ESBL-producing Enterobacteriaceae, MRSA and C. difficile was 57.3% (279/487), 17.2% (84/487) and 5.1% (21/409) respectively. Carriage rate of carbapenemase-producing Enterobacteriaceae was 1% (5/487). Being bedridden was a common independent risk factor for colonization by all MDROs, although risk factors specific for each MDRO were identified. ESBL-producing Escherichia coli carriage was associated with the sequence type (ST) 131-H30 subclone, but other minor STs predominated in individual LTCF or in LTCFs located in the same city, suggesting a role for intrafacility or local transmission. Similarly, MRSA from LTCF residents belonged to the same spa types/ST clones (t008/ST8 and t032/ST22) commonly found in Italian acute-care hospitals, but infrequent spa types were recovered in individual LTCFs. The prevalent C. difficile PCR ribotypes were 356/607 and 018, both common in Italian acute-care hospitals.

CONCLUSIONS

MDRO colonization is common among residents in Italian LTCFs.

Screening for Methicillin-resistant Staphylococcus aureus in a residence home for elderly in Germany

BACKGROUND

Since many hospitals report high MRSA colonization rates among elderly patients, and because it has been shown that S. aureus colonization increases with advancing age, there are concerns about the introduction of MRSA into nursing homes by MRSA positive patients discharged from hospital. So far, admission screening and subsequent longitudinal screening in residence homes or screening at time of hospital discharge is not established on a regular base. On the other hand, MRSA is acquired frequently during hospital stay. Therefore, the MRSA status of residents remains unclear at the time of re-admission to the residence home. This study was conducted to evaluate the rate of nasal MRSA carriage among residents and nursing staffs of 2 nursing homes for the elderly, the potential acquisition of MRSA during a hospital stay and the feasibility to perform direct screening tests in nursing homes for elderly.

METHODS

In a study period of 5 months, possibility of active PCR-based screening for MRSA has been tested within 2 residence homes for the elderly, with the obligation to avoid inconvenience to the daily working time and working schedule. Residents and staff members were included in the study and positive test results were confirmed with MRSA culture.

RESULTS

Feasibility of active on site screening in a residence home for the elderly using a rapid PCR method has been confirmed. 154 of 156 residents participated on baseline testing for all current and new admitted residents. In 9 participating residents with former unknown status, nasal carriage with MRSA was confirmed (5.8%). Among 32 documented and eligible movements between the nursing home and the hospital, MRSA could be confirmed after return to the residence home in 2 cases (6.3%). MRSA could also be detected in 1 of 14 participating nursing staff (7.1%).

CONCLUSION

Prevalence of MRSA was in a range that has been observed for nursing homes in Germany in previous studies. Residents can acquire MRSA during a hospital stay so that further spread after re-admission into the nursing home cannot be excluded. This study shows that easy to perform direct screening tests in outpatient facilities for nursing of the elderly are promising tools as part of potential new strategies for transmission and infection control in such facilities. Additional studies are needed to investigate if screening followed by interventional hygiene measures can reduce MRSA transmission and infection in such facilities.

[Multidrug-resistant bacteria in Germany. The impact of sources outside healthcare facilities]

BACKGROUND

Currently, there is an ongoing discussion about the question whether the emergence of multidrug-resistant microorganisms (MDRO) among humans is due to transfer of these bacteria from animals.

OBJECTIVES

This review summarizes data on the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL) producing enterobacteria in animals and humans, and describes knowledge about transmission pathways.

MATERIAL AND METHODS

After a scientific literature analysis, relevant articles were identified by screening of titles and abstracts, amended by publications of infection control authorities and the respective reference lists.

RESULTS

MDRO are both transmitted in the nosocomial setting and are increasingly detected as sources of infection outside healthcare facilities.

CONCLUSIONS

Due to new transmission pathways of MDRO an inter-disciplinary approach towards prevention is necessary, involving medical, pharmaceutical and veterinary expertise.

MRSA Prevalence and Risk Factors among Health Personnel and Residents in Nursing Homes in Hamburg, Germany - A Cross-Sectional Study

Introduction

The increase of multidrug-resistant organisms in hospitals causes problems in nursing homes. Staff in geriatric nursing homes are at greater risk of MRSA colonisation. The aim of the study was to describe the occupational exposure to MRSA among health personnel in geriatric nursing.

Methods

A point prevalence survey was conducted among health personnel and residents of geriatric nursing homes within the greater Hamburg district. Nasal swabs and, where relevant, wound swabs were collected for the screening survey. Risk factors for MRSA colonisation were identified by means of a questionnaire and using the files held on the residents. Where tests on nursing staff were positive, a control swab was taken; when the results were confirmed positive, decolonisation was performed. The responsible general practitioners were notified of positive MRSA findings among residents. A molecular biological examination of the MRSA samples was performed.

Results

A total of 19 institutions participated in the study. Nasal swabs were taken from 759 nursing staff and 422 residents. Prevalence of MRSA was 1.6% among staff and 5.5% among residents. MRSA colonisation among health personnel indicated a correlation with male gender (OR 4.5, 95% CI 1.4–14.1). Among the residents, chronic skin diseases (OR 3.2, 95% CI 1.0–10.3) and indwelling devices (OR 3.2, 95% CI 1.2–8.1) were identified as risk factors. No link between MRSA in residents and in health personnel could be established.

Conclusion

The number of MRSA colonisations among nursing staff and residents of geriatric nursing homes in Hamburg was rather low at 1.6% and 5.5% respectively and equates to the results of other surveys in non-outbreak scenarios.

[Antibiotic prescription usage and assessment in geriatric patients]

Due to the high risk of infection, the geriatric population is regularly subjected to antibiotics. Faced with bacterial resistance, particularly among elderly dependent patients, it is essential to promote proper use and correct prescription of antibiotics. A study evaluated antibiotic prescription in a geriatric hospital with 598 beds and highlighted the importance of collaboration between geriatricians and infectious disease specialists.

Colonisation with methicillin-resistant Staphylococcus aureus and associated factors among nurses with occupational skin diseases

OBJECTIVES

To evaluate the prevalence of colonisation with methicillin-resistant Staphylococcus aureus (MRSA), associated factors and the effectiveness of decolonisation procedures among nurses with occupational skin diseases (OSD).

METHODS

In a retrospective cohort study, the medical records of 319 nurses from Germany who were screened consecutively for MRSA when participating in a tertiary individual prevention programme (TIP) for severe OSD between July 2009 and December 2014 were evaluated.

RESULTS

90.3% of nurses with severe OSD suffered from hand eczema. 43 were colonised with MRSA on admission (13.5%), mainly in the nose (n=35, 81.4%). However, the hands were affected in more than half of the MRSA carriers (n=24, 55.8%). Risk factors for MRSA colonisation were atopic skin diathesis (OR 2.01, 95% CI 1.03 to 3.92, p=0.049) and presence of atopic dermatitis on other body parts than the hands (OR 4.33, 95% CI 2.23 to 8.43, p<0.001). Hand eczema was significantly more severe in MRSA carriers than in non-carriers (OR 1.23, 95% CI 1.10 to 1.37, p<0.001) and showed a higher prevalence of vesicles, erosions or fissures. MRSA eradication was successful in 67.4% after the first attempt.

CONCLUSIONS

Nurses with OSD have a twofold to threefold higher prevalence of MRSA colonisation than what has been reported for point-prevalence screenings among healthcare workers in Germany. Atopic skin diathesis, atopic dermatitis and severe hand eczema are the main risk factors. Thus, prevention and treatment of OSD could be important elements in reduction of colonisation with MRSA among nurses and transmission to others.

[Epidemiological Survey of the Extended-spectrum β-lactamase-producing Bacteria in Hospitals and Nursing Homes in Morioka Secondary Medical Area Zone of Iwate Prefecture]

The spread of ESBL-producing bacteria (ESBLs) in local communities is a crucially important issue related to infection control. We investigated the relevance of isolation of ESBLs and the risk factors influencing the isolation rates of these organisms at medical facilities (4 rural hospitals, A-D; 4 nursing homes, a-d) located in the Morioka medical area. The isolation rates of ESBLs at 4 hospitals were estimated from the patient medical records from April 2013 to March 2014. Also, ESBLs were isolated from stool samples from residents in 4 nursing homes during almost the same period, and were analyzed to ascertain their genotypes. Furthermore, we compared the isolation rates of ESBLs among four hospitals to determine the influence of use of third-generation cephalosporins and alcohol-based hand rubs, and also among four nursing homes to identify the clinical backgrounds of the nursing home residents influencing the isolation rates. The isolation rates of ESBLs in hospitals and nursing homes were 13.3% (3.6-25.0%) and 9.3% (3.4-21.0%), respectively. Hospital B, which had the highest isolation rate of ESBLs, showed the highest rate of use of third-generation cephalosporins. On the other hand, Hospital A, with a lower isolation rate of ESBLs, showed the highest frequency of use of alcohol rubs. The rate of use of enteral nutrition was significantly higher in the nursing homes with higher isolation rate of ESBLs than those with lower isolation rates (odds ratio 2.71, p < 0.05). Nursing home c, with a significantly higher isolation rate of ESBLs, showed higher usage of adult diapers as well as higher rates of residents with recent hospitalization and high-level care. All ESBLs (13 Escherichia coli) isolated from nursing home c showed the same genotype: CTX-M-3. Although numerous ESBLs were isolated from the hospitals and nursing homes investigated in this study, the isolation rates of ESBLs and the clinical backgrounds of the patients differed greatly among the medical facilities in the same area. Furthermore, as patients and residents were transferred reciprocally among the hospitals and nursing homes, it was suggested that infection control for ESBLs at any individual facility alone was not sufficient and also that cooperative education and information sharing on ESBLs among facilities in the same area might be important.

Simultaneous occurrence of MRSA and ESBL-producing Enterobacteriaceae on pig farms and in nasal and stool samples from farmers

Methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL) producing enterobacteria (ESBL-E) have emerged in livestock. This study prospectively investigates the prevalence of MRSA and ESBL-E on pig farms and in nasal and stool samples from farmers and compares molecular characteristics of these ESBL-E isolates. In 2014, samples were derived at 51 pig farms in Germany. Per farm, five dust and five fecal samples were collected; one nasal and one stool sample were retrieved from farmers. ESBL-E isolates from humans and environmental isolates from the respective farms were characterized using whole genome sequencing for classical multilocus sequence typing (MLST), determination of ESBL-encoding genes and an ad hoc core genome MLST (cgMLST) analysis. MRSA and ESBL-E were detected on 49 (96%) and 31 (61%) of the farms, respectively; in most cases (59%) simultaneously. Nasal MRSA carriage was detected in 72 of 85 (84.7%) farmers and five of 84 (6.0%) farmers carried ESBL-E. ESBL-Escherichia coli isolates from farmers belonged to MLST STs/ESBL-genes ST10/CTX-M-1, ST196/TEM-52, ST278/TEM-52, ST410/CTX-M-15 and ST453/CTX-M-1. In one case, the human ESBL-E isolate was clonally identical to isolates from the farm environment; in the other four cases typing results indicated potential exchange of resistance determinants between human and environmental isolates, but, comparing the isolates within a minimum spanning tree indicated differences in cgMLST-patterns between the farms (p=0.076). This study demonstrated rectal ESBL-E carriage rates among farmers, which were similar to those in the general population. Molecular typing suggested that cross-transmission between the farmers and the farm environment is possible.

Carriage of antimicrobial-resistant commensal bacteria in Dutch long-term-care facilities

OBJECTIVES

The objective of this study was to assess carriage of antimicrobial-resistant commensal microorganisms, i.e. Escherichia coli and Staphylococcus aureus, and its predictors in long-term-care facilities (LTCFs).

METHODS

Nasal swabs and/or urine or incontinence samples were collected from participating residents in 111 LTCFs and tested for the presence of S. aureus and/or E. coli, respectively. Antimicrobial resistance to eight antimicrobials was linked to antimicrobial usage in the year preceding sampling and to LTCF characteristics. Using multilevel logistic regression, predictors of carriage of ESBL-producing E. coli in LTCFs were identified.

RESULTS

S. aureus was identified in 1269/4763 (26.6%) nasal swabs, including 13/4763 (0.3%) MRSA carriers in 9/107 (8%) LTCFs. Of the 5359 urine/incontinence samples, 2934 (55%) yielded E. coli, including 123 (4.2%) producing ESBL, which were found in 53/107 locations (range 1%-33%). For all but one antimicrobial (i.e. nitrofurantoin) >20% of isolated E. coli were resistant. Multilevel multivariable logistic regression identified two predictors of carriage of ESBL-producing E. coli: (i) antimicrobial usage (OR 1.8, 95% CI 1.1-3.0 for each extra 50 DDD/1000 residents/day); and (ii) presence of MRSA carriers in the LTCFs (OR 2.4, 95% CI 1.0-5.6).

CONCLUSIONS

The low proportion of 4.2% ESBL-producing E. coli and the low prevalence of 0.3% MRSA carriage found in LTCF residents suggest that Dutch LTCFs are not yet an important reservoir of MDR potential pathogens. Nevertheless, the large variation between LTCFs warrants close monitoring of antimicrobial resistance in LTCFs. Integrated surveillance, i.e. linking data sources on antimicrobial usage, microbiological testing, clinical background data and epidemiological data, is needed.

Methicillin-Resistant Staphylococcus aureus in Saarland, Germany: The Long-Term Care Facility Study

Background

Multiresistant organisms pose a threat for patients and care recipients. Control interventions need to be tailored to region, the type of institution considered, and risk factors. The German state of Saarland is ideally suited to study colonisation epidemiology throughout its various health and care institutions. After conclusion of a large admission prevalence study in acute care hospitals, we now performed a methicillin-resistant Staphylococcus aureus (MRSA) point prevalence study in Saarland long term care facilities (LTCF), allowing for a direct comparison with respect of MRSA prevalence and associated risk factors between these two institutional types located within a confined region.

Methodology and Principal Findings

Of all LTCF of the region, 65/136 participated in the study performed between 09/2013 and 07/2014. Overall, complete microbiological specimen and questionnaires of 2,858 of 4,275 (66.8%) LTCF residents were obtained. 136/2,858 (4.8%) screened residents revealed MRSA carrier status. Multivariate risk factor analysis yielded ulcer/deep soft tissue infection, urinary tract catheter, and MRSA history with multiple MRSA decolonisation cycles to be independently associated with MRSA carrier status.

Conclusion

As already known from previous studies, colonisation with MRSA is common in LTCF residents even in an area with relatively low MRSA prevalence. This found prevalence can now be related to the acute care admission prevalence (2.2%) as well as to the admission prevalence in acute care geriatric departments (7.6%). The common clonal attribution (spa type) of MRSA isolates prevalent in the LTCF population as well as in the acute care admission population points towards a close relationship between both types of institutions. However, the ostensible absence of risk factors such as “previous hospitalisation” in conjunction with newly identified factors such as “multiple decolonisation cycles” refers to MRSA colonisation risks independent of contact with acute care facilities. Overall, this large LTCF point prevalence study allows data-based, region-tailored decisions on MRSA screening policies and provides a basis for additional preventative measures.

The prevalence of ESBL-producing Enterobacteriaceae in a nursing home setting compared with elderly living at home: a cross-sectional comparison

Background

The aim of the study was to investigate the prevalence of faecal carriage of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae among residents living in nursing homes and to compare it with a corresponding group of elderly people living in their own homes.

Methods

A total of 160 persons participated in the study between February and April 2014, 91 were residents in nursing homes (n = 10) and the remaining 69 were elderly living in their own homes. In addition to performing faecal samples, all participants answered a standardized questionnaire regarding known risk factors for ESBL-carriage.

Results

There was no significant difference between the groups, as 10 of the 91 (11 %) residents from nursing homes were ESBL-carriers compared with 6 of 69 (8,7 %) elderly living in their own homes. There was no significant difference between the groups. The total prevalence was 10 %. A univariate analysis revealed that the only studied risk factor significantly associated with ESBL-carriage was recent foreign travel (p = 0,017). All ESBL-positive isolates were Escherichia coli and there was a high degree of co-resistance to other antibiotics. All isolates (n = 17) were susceptible to imipenem and amikacin.

Conclusion

Residents of nursing homes as well as elderly living in their own homes have high rates of faecal carriage of ESBL-producing bacteria. These findings may affect the choice of empirical antibiotic treatment of severe infections in older adults.

[Healthcare-associated infections and antimicrobial use in long term care facilities (HALT-2): German results of the second European prevalence survey]

Prevention of infections and strategies for the prudent use of antimicrobials in long-term care facilities have gained importance in view of the demographic changes, not only in Germany. To generate appropriate data and to identify relevant aspects of infection prevention in this field, the European Centre for Disease Prevention and Control (ECDC) launched the second point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities in 2013 (HALT-2). Despite methodical adjustments in the collection of data on healthcare-associated infections, in this second survey healthcare workers in the participating facilities were intensively trained in methodology and data collection. Overall, 221 German facilities participated and collected data from 17,208 residents. Well-established structures of regional networks facilitated the recruitment of participants as well as the preparations for training and survey. The median prevalence of residents receiving at least one antimicrobial agent was 1.1% (95 %-CI 0,7-1,6)), which is remarkably low. However, the most frequently used antimicrobials in German facilities beside beta-lactams (penicillins 18.2%, other beta-lactams 17.2%) were quinolones (28.2%). Data collection of infections was performed based on signs and symptoms in detailed decision algorithms according to the recently updated McGeer surveillance criteria and yielded a median prevalence of 1.7% (95 %-CI 1,1-2,2). Symptomatic urinary tract infections (28.4%), skin and soft tissue infection (27.9%), and respiratory tract infections (24.7%) were identified both as the most common types of infections and the most common indications for the use of systemic antimicrobials. Clinical implications evolve mainly from the high use of quinolones. In terms of infection prevention measures, compliance of health care workers with a hand hygiene regimen revealed further potential for improvement.

Whole-genome sequencing reveals transmission of vancomycin-resistant Enterococcus faecium in a healthcare network

Background

Bacterial whole-genome sequencing (WGS) has the potential to identify reservoirs of multidrug-resistant organisms and transmission of these pathogens across healthcare networks. We used WGS to define transmission of vancomycin-resistant enterococci (VRE) within a long-term care facility (LTCF), and between this and an acute hospital in the United Kingdom (UK).

Methods

A longitudinal prospective observational study of faecal VRE carriage was conducted in a LTCF in Cambridge, UK. Stool samples were collected at recruitment, and then repeatedly until the end of the study period, discharge or death. Selective culture media were used to isolate VRE, which were subsequently sequenced and analysed. We also analysed the genomes of 45 Enterococcus faecium bloodstream isolates collected at Cambridge University Hospitals NHS Foundation Trust (CUH).

Results

Forty-five residents were recruited during a 6-month period in 2014, and 693 stools were collected at a frequency of at least 1 week apart. Fifty-one stool samples from 3/45 participants (7 %) were positive for vancomycin-resistant E. faecium. Two residents carried multiple VRE lineages, and one carried a single VRE lineage. Genome analyses based on single nucleotide polymorphisms (SNPs) in the core genome indicated that VRE carried by each of the three residents were unrelated. Participants had extensive contact with the local healthcare network. We found that VRE genomes from LTCF residents and hospital-associated bloodstream infection were interspersed throughout the phylogenetic tree, with several instances of closely related VRE strains from the two settings.

Conclusions

A proportion of LTCF residents are long-term carriers of VRE. Evidence for genetic relatedness between these and VRE associated with bloodstream infection in a nearby acute NHS Trust indicate a shared bacterial population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13073-015-0259-7) contains supplementary material, which is available to authorized users.

Incidence of invasive meticillin-resistant Staphylococcus aureus infections in Germany, 2010 to 2014

Voluntary surveillance systems in Germany suggest a recent decline in the incidence of infections (subsequent to at least 2010) with meticillin-resistant Staphylococcus aureus (MRSA) from various types of specimens and settings. We asked whether this decline is reflected by data from the mandatory national surveillance system for invasive MRSA infections. Our analysis is based on the population in Germany in 2010 to 2014. Cases were identified from passive reporting by microbiological laboratories of the diagnosis of MRSA from blood culture or cerebrospinal fluid. Respective clinical data were subsequently added to the notification. We calculated risk ratios (RR) between consecutive years, stratifying cases by sex, age and federal state of residence. The national incidence increased from 4.6 episodes per 100,000 persons in 2010 to 5.6 in 2012 (2011 vs 2010: RR: 1.13, 95% confidence interval (CI): 1.08–1.18; 2012 vs 2011: RR: 1.08, 95% CI: 1.04–1.13). It stagnated at 5.4 per 100,000 in 2013 (RR: 0.97, 95% CI: 0.93–1.01) before declining to 4.8 in 2014 (RR: 0.88, 95% CI: 0.84–0.91). This trend was observed in most, but not all federal states and strata of sex and age groups. Only 204 of 20,679 (1%) episodes of infection were notified as belonging to an outbreak. Our analysis corroborates previous findings that the incidence of invasive MRSA infections in Germany may be declining.