A Novel Risk Factor Associated With Colonization by Carbapenemase-Producing Enterobacteriaceae: Use of Proton Pump Inhibitors in Addition to Antimicrobial Treatment

Treatment with proton pump inhibitors is associated with secondary bacterial infections and sepsis in patients with COVID-19: a retrospective analysis of their joint impact on in-hospital prognosis

Introduction and objectives. Secondary bacterial infections (SBIs) contribute to worse in-hospital outcomes in patients with Coronavirus disease 2019 (COVID-19). Treatment with proton pump inhibitors (PPIs) is associated with an increased risk of bacterial infections in different clinical settings. However, the association between PPI treatment prior to hospital admission and the occurrence of either SBIs or secondary bacterial sepsis (SBS) as well as their joint impact on clinical outcomes of patients hospitalized for COVID-19 are not clarified.

Patients and methods. We retrospectively analyzed preadmission PPI use, in-hospital occurrence of SBIs and SBS, and in-hospital outcomes of a cohort of patients hospitalized for COVID-19.

Results. Among 1087 patients, 447 (41%) were on PPI treatment prior to hospital admission. During the hospital stay, 197 (18%) and 223 (20%) patients were diagnosed with SBIs and SBS, respectively. The composite endpoint of intensive care unit (ICU) admission/in-hospital death was met by 214 (20%) patients. Preadmission PPI treatment was independently associated with up to a 2.1-fold and 1.7-fold increased risk of SBIs and SBS, respectively. The occurrence of SBS was independently associated with up to a 2.2-fold increased risk of ICU admission/in-hospital death. A significant preadmission PPI treatment x SBS interaction emerged in predicting ICU admission/in-hospital death (F = 5.221, pinteraction = 0.023).

Conclusions. PPI treatment prior to hospital admission for COVID-19 is associated with an increased risk of SBIs and SBS. In addition, it interacts with SBS in predicting in-hospital prognosis. An appropriate use of PPIs may attenuate the risk of adverse clinical outcomes during hospitalization for COVID-19.

Proton pump inhibitors and risk of severe COVID-19 in older people

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 is a viral respiratory infection that can cause systemic disorders and lead to death, particularly in older people. Proton pump inhibitors (PPIs) increase the risk of enteric and lung infections. Considering the broad use of PPIs in older people, the potential role of PPIs in COVID-19 could be of dramatic significance. The objective of our study was to evaluate the link between PPIs and severe COVID-19 in older people.

METHOD

We performed a retrospective cohort study, including all patients aged ≥65, hospitalised for a diagnosis of COVID-19. Epidemiological, clinical and biological data were extracted and we performed an Inverse Probability of Treatment Weighing method based on a propensity score.

RESULTS

From March 2020 to February 2021, a total of 834 patients were included, with a median age of 83 and 52.8% were male. A total of 410 patients had a PPIs prescription, 358 (87.3%) were long-term PPIs-users and 52 (12.7%) were recent PPIs-users. Among PPIs-users, 163 (39.8%) patients developed severe COVID-19 versus 113 (26.7%) in PPIs-non users (odds ratio (OR) = 1.59 [1.18-2.14]; P < 0.05). Moreover, the double dose PPI-users had a higher risk of developing severe COVID-19 (OR = 3.36 [1.17-9.66]; P < 0.05) than the full dose PPI-users (OR = 2.15 [1.22-3.76]; P < 0.05) and the half dose PPI-users (OR = 1.64 [1.13-2.37]; P < 0.05).

CONCLUSION

Our study reports evidence that the use of PPIs was associated with an increased risk of severe COVID-19 in older people.

Proton pump inhibitors increase the risk of carbapenem-resistant Enterobacteriaceae colonization by facilitating the transfer of antibiotic resistance genes among bacteria in the gut microbiome

Carbapenem-resistant Enterobacteriaceae (CRE) pose a global health threat; however, there is still limited understanding of the risk factors and underlying mechanisms of CRE colonization in the gut microbiome. We conducted a matched case-control study involving 282 intensive care unit patients to analyze influencing covariates on CRE colonization. Subsequently, their effects on the gut microbiome were analyzed in a subset of 98 patients (47 CRE carriers and 51 non-CRE carriers) using whole metagenome sequences. The concomitant use of proton pump inhibitors (PPIs) and antibiotics was a significant risk factor for CRE colonization. The gut microbiome differed according to PPI administration, even within the CRE and non-CRE groups. Moreover, the transfer of mobile genetic elements (MGEs) harboring carbapenem resistance genes (CRGs) between bacteria was higher in the PPI-treated group than in the PPI-not-treated group among CRE carriers. The concomitant use of PPIs and antibiotics significantly alters the gut microbiome and increases the risk of CRE colonization by facilitating the transfer of CRGs among bacteria of the gut microbiome. Based on these findings, improved stewardship of PPIs as well as antibiotics can provide strategies to reduce the risk of CRE colonization, thereby potentially improving patient prognosis.

Epidemiology of multidrug-resistant organisms before and during COVID-19 in Hong Kong

Background

The coronavirus disease 2019 (COVID-19) has influenced antimicrobial consumption and incidence of multidrug-resistant organisms (MDROs). We aimed to study the epidemiology of MDROs before and during the COVID-19 pandemic in Hong Kong.

Methods

With the maintenance of infection control measures, we described the trend of MDRO infections, including methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum-beta-lactamase-(ESBL)-producing Enterobacterales, in a healthcare region with 3100-bed before (1 January 2016 to 31 December 2019, period 1) and during COVID-19 (1 January 2020 to 30 September 2022, period 2), together with the antimicrobial consumption using piecewise Poisson regression. The epidemiological characteristics of newly diagnosed COVID-19 patients with or without MDRO infections were analyzed.

Results

Between period 1 and 2, we observed a significant increase in the trend of CRA infections (P<0.001), while there was no significant increase in the trend of MRSA (P=0.742) and ESBL-producing Enterobacterales (P=0.061) infections. Meanwhile, a significant increase in the trend of carbapenems (P<0.001), extended-spectrum beta-lactam-beta-lactamase inhibitor combinations (BLBI) (P=0.045), and fluoroquinolones (P=0.009) consumption was observed. The observed opportunity (23,540 ± 3703 vs 26,145 ± 2838, p=0.359) and compliance (81.6% ± 0.5% vs 80.1% ± 0.8%, P=0.209) of hand hygiene per year was maintained. In a multivariable model, older age, male sex, referral from residential care home for the elderly, presence of indwelling device, presence of endotracheal tube, and use of carbapenems, use of BLBI, use of proton pump inhibitors and history of hospitalization in the past 3 months were associated with higher risks of infections by MDROs among COVID-19 patients.

Conclusion

Infection control measures may control the surge of MDROs despite an increasing trend of antimicrobial consumption.

Modifiable risk factors associated with later gut decolonization of carbapenem-resistant Gram-negative bacteria in children: A prospective cohort study

BACKGROUND

Nosocomial infections caused by carbapenem-resistant gram-negative bacteria (CRGNB) are associated with increased mortality and prolonged hospitalization; thus, later CRGNB-decolonization has significant clinical and public health implications.

AIM

We investigated modifiable/ non-modifiable risk factors for CRGNB-later gut decolonization in children.

METHODS

We included CRGNB-carriers (1day-16years old), hospitalized in a tertiary-level hospital (2018-2019). Upon CRGNB-carriage detection, rectal-swab cultures were taken weekly, if patients were hospitalized and monthly after discharge for 12 months. CRGNB-decolonization was defined as three consecutive negative rectal-swab cultures obtained ≥1 week apart. Modifiable (treatment administered/medical devices) and non-modifiable (age/gender/comorbidities) risk factors were recorded. Cox regression for later CRGNB-decolonization was performed.

FINDINGS

One hundred thirty CRGNB-carriers were recorded. After 12 months, 5.4% remained carriers. Risk factors for later decolonization were immunosuppression (HR: 0.52, 95%CI: 0.31-0.87), carbapenems (HR: 0.52, 95%CI: 0.30-0.91), proton-pump inhibitors (PPIs) (HR: 0.39, 95%CI: 0.24-0.64) and their duration of use, duration of hospitalization (HR: 0.90, 95%CI: 0.81-0.92, per 10 days), number of re-admissions (HR: 0.90, 95%CI: 0.86-0.96), abdominal surgery (HR: 0.33, 95%CI: 0.17-0.65), urinary catheter (HR: 0.42, 95%CI: 0.24-0.76) and duration of steroid administration (HR: 0.86, 95%CI: 0.84-0.88, per 10 days).

CONCLUSIONS

Carbapenems, PPIs and their duration of use, duration of steroids use, immunosuppression, urinary catheter, re-admissions, duration of hospitalization, and abdominal surgery are associated with later CRGNB-decolonization among children. Paediatric patients at risk of later decolonization should be under targeted screening and preemptive contact precautions. Known carriers at risk of later CRGNB-decolonization should be under meticulously applied contact precautions for longer durations.

Time to intestinal clearance of carbapenemase-producing Enterobacterales in hospital patients: a longitudinal retrospective observational cohort study

BACKGROUND

Intestinal clearance of carbapenemase-producing Enterobacterales (CPE-IC) is a cornerstone to discontinue isolation precautions for CPE patients in hospitals. This study aimed to evaluate the time to spontaneous CPE-IC and identify its potential associated risk factors.

METHODS

This retrospective cohort study was carried out between January 2018 and September 2020 on all patients in a 3200-bed teaching referral hospital with confirmed CPE intestinal carriage. CPE-IC was defined as at least three consecutive CPE-negative rectal swab cultures without a subsequent positive result. A survival analysis was performed to determine the median time to CPE-IC. A multivariate Cox model was implemented to explore the factors associated with CPE-IC.

RESULTS

A total of 110 patients were positives for CPE, of whom 27 (24.5%) achieved CPE-IC. Median time to CPE-IC was 698 days. Univariate analysis showed that female sex (P=0.046), multiple CPE-species in index cultures (P=0.005), Escherichia coli or Klebsiella spp. (P=0.001 and P=0.028, respectively) were significantly associated with the time to CPE-IC. Multivariate analysis highlighted that identification of E. coli carbapenemase-producing or CPEs harbouring ESBL genes in index culture extended the median time to CPE-IC, respectively (adjusted hazard ratio (aHR) = 0.13 (95% confidence interval: 0.04-0.45]; P=0.001 and aHR = 0.34 (95% confidence interval: 0.12-0.90); P=0.031).

CONCLUSION

Intestinal decolonization of CPE can take several months to years to occur. Carbapenemase-producing E. coli are likely to play a key role in delaying intestinal decolonization, probably through horizontal gene transfer between species. Therefore, discontinuation of isolation precautions in CPE-patients should be considered with caution.

Clinical Risk Factors and Microbiological and Intestinal Characteristics of Carbapenemase-Producing Enterobacteriaceae Colonization and Subsequent Infection

Gastrointestinal colonization with carbapenem-resistant Enterobacteriaceae (CRE) is always a prerequisite for the development of translocated infections. Here, we sought to screen for fecal carriage of CRE and identify the risk factors for CRE colonization as well as subsequent translocated pneumonia in critically ill patients admitted to the intensive care unit (ICU) of a university hospital in China. We further focused on the intestinal flora composition and fecal metabolic profiles in CRE rectal colonization and translocated infection patients. Animal models of gastrointestinal colonization with a carbapenemase-producing Klebsiella pneumoniae (carbapenem-resistant K. pneumoniae [CRKP]) clinical isolate expressing green fluorescent protein (GFP) were established, and systemic infection was subsequently traced using an in vivo imaging system (IVIS). The intestinal barrier, inflammatory factors, and infiltrating immune cells were further investigated. In this study, we screened 54 patients hospitalized in the ICU with CRE rectal colonization, and 50% of the colonized patients developed CRE-associated pneumonia, in line with the significantly high mortality rate. Upon multivariate analysis, risk factors associated with subsequent pneumonia caused by CRE in patients with fecal colonization included enteral feeding and carbapenem exposure. Furthermore, CRKP colonization and translocated infection influenced the diversity and community composition of the intestinal microbiome. Downregulated propionate and butyrate probably play important and multiangle roles in regulating immune cell infiltration, inflammatory factor expression, and mucus and intestinal epithelial barrier integrity. Although the risk factors and intestinal biomarkers for subsequent infections among CRE-colonized patients were explored, further work is needed to elucidate the complicated mechanisms. IMPORTANCE Carbapenem-resistant Enterobacteriaceae have emerged as a major threat to modern medicine, and the spread of carbapenem-resistant Enterobacteriaceae is a clinical and public health problem. Gastrointestinal colonization by potential pathogens is always a prerequisite for the development of translocated infections, and there is a growing need to assess clinical risk factors and microbiological and intestinal characteristics to prevent the development of clinical infection by carbapenem-resistant Enterobacteriaceae.

Control of Healthcare-Associated Carbapenem-Resistant Acinetobacter baumannii by Enhancement of Infection Control Measures

Antimicrobial stewardship and infection control measures are equally important in the control of antimicrobial-resistant organisms. We conducted a retrospective analysis of the incidence rate of hospital-onset carbapenem-resistant Acinetobacter baumannii (CRAB) infection (per 1000 patient days) in the Queen Mary Hospital, a 1700-bed, university-affiliated teaching hospital, from period 1 (1 January 2007 to 31 December 2013) to period 2 (1 January 2014 to 31 December 2019), where enhanced infection control measures, including directly observed hand hygiene before meal and medication rounds to conscious patients, and the priority use of single room isolation, were implemented during period 2. This study aimed to investigate the association between enhanced infection control measures and changes in the trend in the incidence rate of hospital-onset CRAB infection. Antimicrobial consumption (defined daily dose per 1000 patient days) was monitored. Interrupted time series, in particular segmented Poisson regression, was used. The hospital-onset CRAB infection increased by 21.3% per year [relative risk (RR): 1.213, 95% confidence interval (CI): 1.162−1.266, p < 0.001], whereas the consumption of the extended spectrum betalactam-betalactamase inhibitor (BLBI) combination and cephalosporins increased by 11.2% per year (RR: 1.112, 95% CI: 1.102−1.122, p < 0.001) and 4.2% per year (RR: 1.042, 95% CI: 1.028−1.056, p < 0.001), respectively, in period 1. With enhanced infection control measures, the hospital-onset CRAB infection decreased by 9.8% per year (RR: 0.902, 95% CI: 0.854−0.953, p < 0.001), whereas the consumption of the extended spectrum BLBI combination and cephalosporins increased by 3.8% per year (RR: 1.038, 95% CI: 1.033−1.044, p < 0.001) and 7.6% per year (RR: 1.076, 95% CI: 1.056−1.097, p < 0.001), respectively, in period 2. The consumption of carbapenems increased by 8.4% per year (RR: 1.84, 95% CI: 1.073−1.094, p < 0.001) in both period 1 and period 2. The control of healthcare-associated CRAB could be achieved by infection control measures with an emphasis on directly observed hand hygiene, despite an increasing trend of antimicrobial consumption.

A Longitudinal Study of Spontaneous Gut Decolonization of Carbapenem-resistant Gram-negative Bacteria in Neonatal and Pediatric Patients

BACKGROUND

Antibiotic exposure may convert gut microbiome to reservoir of resistant organisms, including carbapenem-resistant Gram-negative bacteria (CRGNB). Little is known about natural history of spontaneous CRGNB decolonization of neonates/children and their risk to develop CRGNB infections.

METHODS

Patients hospitalized in a tertiary care hospital (1 days to 16 years) found to be CRGNB colonized in weekly surveillance cultures during hospitalization (January 2018 to December 2019) were prospectively followed after discharge with monthly rectal cultures for 12 months after colonization until decolonization (3 consecutive negative rectal cultures, ≥1 week apart). Patient demographics, clinical characteristics and CRGNB infections were recorded. Polymerase chain reaction for carbapenemases was performed in patients colonized, after 3 negative cultures, at the day of the last negative and the day of the first new positive culture.

RESULTS

One-hundred thirty patients (median age, 1.3 months; lower-upper quartile values, 0.8-6.9 months) were studied including 66 neonates (median age, 12.6 days; Q1-Q3, 5-18.5 days). Among patients >30 days old, 51.6% achieved decolonization within 6 months, and among neonates, 91% achieved decolonization within 6 months. By 12th month, 89% of >30 days and 100% of neonates were decolonized. Forty-four (33.9%) patients (59% >30 days and 9% neonates) developed CRGNB infection(s), mainly pneumonia (25%) and bloodstream infection (20.5%). Prolonged colonization (odds ratio [OR], 7.75; 95% confidence interval [CI], 2.10-28.58), duration of broad-spectrum antibiotic use (OR, 1.22; 95% CI, 1.11-1.34) and parenteral nutrition (OR, 4.53; 95% CI, 1.14-17.94) were associated with the development of CRGNB infection. Two patients (1.5%) were found by polymerase chain reaction colonized after 3 negative cultures.

CONCLUSIONS

Spontaneous decolonization occurs in most CRGNB colonized >30 days and all neonates within 12 months. One-third of colonized patients develop CRGNB infection(s). These findings may help optimize duration of contact precautions and empirical antimicrobial therapy for CRGNB colonized pediatric patients.

Gastrointestinal colonization of methicillin-resistant Staphylococcus aureus: an unrecognized burden in the hospital infection control

The incidence, risk factors, outcomes, and genomic relatedness of patients with newly diagnosed gastrointestinal colonization of meticillin-resistant Staphylococcus aureus (MRSA) were analyzed epidemiologically and genetically by whole genome sequencing (WGS) in a hospital network in Hong Kong. Between 1 October 2015 and 31 December 2018, 919 (2.7%) of 34,667 patients had newly diagnosed gastrointestinal MRSA colonization by admission screening. The incidence was 0.67±0.32 per 1,000-patient-days-per-quarter. Including patients with gastrointestinal MRSA colonization, the overall burden of MRSA increased by 59.2% (from 1.13±0.13 to 1.80±0.36 case per 1,000-patient-days-per-quarter), with an addition of MRSA 4,727 patient-days during the study period. Patients referred from residential care home for the elderly [odds ratio (95% confidential interval): 4.18 (3.50-4.99), p<0.001], with history of hospitalization in the past 6 months [1.90 (1.56-2.30), p<0.001], and consumption of fluoroquinolones [1.76 (1.34-2.30), p<0.001], cephalosporins [1.61 (1.11-2.31), p=0.011], and proton pump inhibitors [1.31 (1.10-1.56), p=0.002] in the preceding 6 months were found to be independent risk factors by multivariable analysis in the case-control analysis. The median survival of case was significantly shorter than control (860 vs 1507 days, p<0.001). 127 (13.8%) of 919 patients developed symptomatic MRSA infection in 112 days (median, range: 2-712 days). Of 19 patients with paired MRSA faecal and blood culture isolates subjected to WGS, clonality was found in 16 (84.2%) pairs of MRSA isolates. MRSA ST45 constituted 44.7% (17/38) of MRSA isolates. Gastrointestinal MRSA colonization may contribute to adverse clinical outcomes and pose an unrecognized burden to the hospital infection control.

The use of multi-pronged screening strategy to understand the epidemiology of carbapenemase-producing Enterobacteriaceae in Hong Kong: transition from epidemic to endemic setting

A multi-pronged carbapenemase-producing Enterobacteriaceae (CPE) screening strategy was implemented in Hong Kong West healthcare network. Of 199,192 fecal specimens from 77,194 patients screening from 1 July 2011 to 30 June 2019, the incidence of CPE per 1000 patient admission significantly increased from 0.01 (2012) to 1.9 (2018) (p<0.01). With appropriate infection control measures, the incidence of nosocomial CPE per 1000 CPE colonization day decreased from 22.34 (2014) to 10.65 (2018) (p=0.0094). Exposure to wet market for purchasing raw pork (p=0.007), beef (p=0.017), chicken (p=0.026), and vegetable (p=0.034) for >3 times per week significantly associated with community acquisition of CPE. Strategic CPE control measures should be implemented in both the hospital and the community.

Prolonged Carriage of Carbapenemase-Producing Enterobacteriaceae: Clinical Risk Factors and the Influence of Carbapenemase and Organism Types

Prolonged carriage of carbapenemase-producing Enterobacteriaceae (CPE) constitutes a substantial epidemiologic threat. This study aimed to evaluate whether the types of carbapenemase and organism can affect the duration of carriage and to evaluate the clinical factors associated with prolonged carriage. We retrospectively reviewed data for patients admitted between May 2013 and August 2018 who were identified as CPE carriers. A total of 702 patients were identified; the major types of carbapenemase and organism were Oxacillinase (OXA)-48-like (n = 480, 68.4%) and Klebsiella pneumoniae (K. pneumoniae) (n = 584, 83.2%). The analyses of time to spontaneous decolonization using the Kaplan–Meier method showed that OXA-48-like and K. pneumoniae were significantly associated with prolonged carriage (log rank, p = 0.001 and p < 0.001). In multivariable logistic analysis to assess the risk factors for CPE prolonged carriage in the 188 patients with available follow-up culture data for 3 months, K. pneumoniae (adjusted odds ratio [aOR] 6.58; 95% confidence interval [CI], 1.05–41.27; p = 0.044), CPE positive clinical specimen (aOR 11.14; 95% CI, 4.73–26.25; p < 0.001), and concurrent Clostridioides difficile infection (CDI) (aOR 3.98, 95% CI 1.29–12.26; p = 0.016) were predictive of prolonged carriage. Our results suggest that CP-K. pneumoniae may have higher probability of prolonged carriage, while the effect of OXA-48-like CPE is inconclusive. Furthermore, patients with CP-K. pneumoniae who had positive clinical specimen or concurrent CDI can cause a vicious circle in prolonged carriage.

[Use and management of proton pump inhibitors: An observational study]

INTRODUCTION

Proton pump inhibitors (PPIs) have improved the management and prevention of digestive diseases, leading to a heavy prescription of this therapy. In 2015, nearly one quarter of the French population had consumed a PPI and half of them were long-term users. The main objective of this study was to analyze, in patients hospitalized in several medical departments, the adequacy of long-term PPI prescriptions to recommendations.

METHOD

The Use and management of proton pump inhibitors: an observational study project (UTOPPIA) is a longitudinal observational study conducted at the University Hospital of Saint-Étienne in the departments of hepato-gastroenterology, infectious and tropical diseases, internal medicine, vascular medicine and nephrology. All patients with PPI treatment on their usual outpatient prescription were interviewed.

RESULTS

Over a 3-month period, 334 of hospitalized patients (30.7%) had received a long-term PPI prescription and 181 patients (54.2%) could be included in the study for a total of 274 indications. Ninety-nine patients (54.7%) had a long-term PPI prescription in accordance with the recommendations. The most frequent indication (70 prescriptions) was the prescription of an antiplatelet drug or anticoagulant for subjects at high risk of bleeding in 70 prescriptions. Fifty-three PPI treatments were amended during the hospital stay, including 9 discontinuations. The justification for the change was documented in the patients' chart in only 17% of cases. Individual interviews of patients revealed that 75.1% of them were in favour of discontinuing their PPI treatment.

CONCLUSIONS

About one-third of hospitalized patients in medical wards in France have long-term PPI treatment and half of these prescriptions do not comply with good practice recommendations. A majority of patients report being willing to try to stop PPI therapy.

Evaluation of the Association Between Gastric Acid Suppression and Risk of Intestinal Colonization With Multidrug-Resistant Microorganisms: A Systematic Review and Meta-analysis

IMPORTANCE

Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome. Whether acid suppression increases the risk of colonization with multidrug-resistant microorganisms (MDROs) is unclear.

OBJECTIVES

To systematically examine the association of use of acid suppressants with the risk of colonization with MDROs and to perform a meta-analysis of current evidence.

DATA SOURCES

PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched from database inception through July 8, 2019.

STUDY SELECTION

Study selection was performed independently by 2 authors (R.P.J.W. and C.M.J.E.V.-G.) on the basis of predefined selection criteria; conflicts were resolved by consensus or by an adjudicator (K.v.D.). Human observational studies (case control, cohort, and cross-sectional) and clinical trial designs were selected if they quantified the risk of MDRO colonization in users of acid suppressants in comparison with nonusers.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendations were followed. Data were extracted independently by the same 2 authors, and adjudication was conducted when necessary. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were estimated using random-effects models; heterogeneity was evaluated using the I2 method.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was intestinal colonization with MDROs of the Enterobacterales order (producing extended-spectrum β-lactamases, carbapenemases, or plasmid-mediated AmpC β-lactamases), vancomycin-resistant enterococci, methicillin-resistant or vancomycin-resistant Staphylococcus aureus, or multidrug-resistant Pseudomonas or Acinetobacter species.

RESULTS

A total of 26 observational studies including 29 382 patients (11 439 [38.9%] acid suppressant users) met the selection criteria. Primary meta-analysis of 12 studies including 22 305 patients that provided adjusted ORs showed that acid suppression increased the odds of intestinal carriage of MDROs of the Enterobacterales order and of vancomycin-resistant enterococci by roughly 75% (OR = 1.74; 95% CI, 1.40-2.16; I2 = 68%). The odds were concordant with the secondary pooled analysis of all 26 studies (OR = 1.70; 95% CI, 1.44-1.99; I2 = 54%). Heterogeneity was partially explained by variations in study setting and the type of acid suppression.

CONCLUSIONS AND RELEVANCE

Acid suppression is associated with increased odds of MDRO colonization. Notwithstanding the limitations of observational studies, the association is plausible and is strengthened by controlling for confounders. In view of the global increase in antimicrobial resistance, stewardship to reduce unnecessary use of acid suppressants may help to prevent MDRO colonization.

Faecal microbiota transplantation for eradicating carriage of multidrug-resistant organisms: a systematic review

BACKGROUND

Multidrug-resistant (MDR) microorganism development in the gut is frequently the result of inappropriate antibiotic use. Faecal microbiota transplantation (FMT) restores normal gut microbiota in patients with Clostridium difficile infection. We hypothesized that it may help in decolonizing MDR organisms (MDROs) and in preventing recurrent MDR infections.

OBJECTIVES

To assess FMT efficacy (eradication rate) for decolonizing MDROs and preventing recurrent MDR infections.

DATA SOURCES

Medline, Embase and Web of Science (inception through 11 February 2019).

STUDY ELIGIBILITY CRITERIA

Clinical trials, retrospective studies, case reports and case series.

PARTICIPANTS

Patients with MDR infections or MDRO colonization treated with FMT.

INTERVENTIONS

FMT.

METHODS

Systematic review.

RESULTS

Twenty-one studies (one randomized clinical trial, seven uncontrolled clinical trials, two retrospective cohort studies, two case series, nine case reports) assessing 192 patients were included. Three studies assessed FMT efficacy in preventing MDR infections; 16 assessed its effect on MDRO colonization; two assessed both. Data from 151 patients were included in the final analyses. In studies with low to moderate risk of bias, the eradication rate was 37.5% to 87.5%. Efficacy was similar in studies looking at infection or colonization and did not differ by length of follow-up. No serious adverse events from FMT were reported. Seven patients died of other causes.

CONCLUSIONS

FMT could be used as a treatment for eradicating MDR colonization and possibly preventing recurrent MDR infections, once more supporting efficacy and safety data are available. Larger well-designed randomized controlled trials are needed to further explore this therapy.

Active Surveillance of Carbapenemase-Producing Organisms (CPO) Colonization With Xpert Carba-R Assay Plus Positive Patient Isolation Proves to Be Effective in CPO Containment

Background: Rapid screening of patients for colonization with carbapenemase-producing organisms (CPO), coupled with implementation of infection prevention strategies, has the potential to contain the spread of CPO.

Methods: We first evaluated the performance of Xpert Carba-R assay (in comparison with other phenotypic methods) for carbapenemase detection using clinical isolates, and then used it to determine the intestinal CPO colonization in hospitalized patients. We then assessed the effectiveness of patient isolation in controlling the spread of CPO in a medical intensive care unit.

Results: The Xpert Carba-R assay required the least processing time to reveal results and showed a 94.5% sensitivity and specificity in carbapenemase detection, except for IMP-8 (n = 4). During a 6-month study period, 134 patients in one ward were studied for CPO colonization and infection. Fifteen patients (11.2%) were colonized by CPO as detected by Xpert Carba-R assay, including three NDM, three IMP, and nine KPC possessing strains. The overall colonization and CPO infection rates were both 11.2% each. Isolation of patients with CPO led to a reduction in both colonization (from 28.6 to 5.6%) and infection rates (from 35.7 to 2.8%) during the study period (p < 0.05).

Conclusion: Active surveillance of CPO utilizing the Xpert Carba-R assay supplemented with immediate patient isolation, proved to be an effective strategy to limit the spread of CPO in a health care setting.

Phenotypic and molecular detection methods for carbapenemase-producing organisms and their clinical significance at two Scottish tertiary care hospitals

PURPOSE

This study evaluated in-house PCR testing for local identification of bacteria carrying the major carbapenemase genes (blaOXA-48-like, blaVIM, blaNDM, blaKPC and blaIMP).

METHODOLOGY

Carbapenemase-producing organisms (CPOs) isolated from patients managed in two tertiary care hospitals in Scotland from September 2014-January 2017 were investigated. A combination of chromogenic screening agar (ChromID CARBA SMART), a carbapenem hydrolysis test (Rapidec Carba NP) and in-house real-time PCR for the blaOXA-48-like, blaVIM, blaNDM, blaKPC and blaIMP genes were utilized. All isolates were sent to the AMRHAI reference unit for confirmatory testing.

RESULTS

During the 29-month study period 39 CPO were isolated from 34 patients. The average turnaround time for a workflow involving phenotypic and molecular testing was 4.2 days. PCR had a sensitivity and specificity of 100 %. The most common carbapenemase genes were blaOXA-48-like (31%), blaVIM (23%) and blaNDM (20%). Resistance to antimicrobials other than beta-lactams was common; the most active agents were colistin, amikacin and fosfomycin. Twenty-seven patients were considered to be colonized (although CPO detection influenced empiric antimicrobials in five) and a CPO was implicated in infection in seven patients (bacteraemia in immunocompromised patients, n=2; surgical site infections, n=2; osteomyelitis in a patient with diabetes mellitus, n=1; and urinary tract infections, n=2). All patients survived infection.

CONCLUSION

In a lowincidence setting we demonstrate the efficacy of a combined local laboratory workflow for rapid detection of CPOs, incorporating phenotypic and molecular testing. In 7/34 patients the CPO was implicated as a pathogen and detection influenced antimicrobial decision-making in five colonized patients.

Nosocomial transmission of hepatitis C virus in a liver transplant center in Hong Kong: implication of reusable blood collection tube holder as the vehicle for transmission

BACKGROUND

A liver transplant recipient developed hospital-acquired symptomatic hepatitis C virus (HCV) genotype 6a infection 14 months post transplant.

OBJECTIVE

Standard outbreak investigation.

METHODS

Patient chart review, interviews of patients and staff, observational study of patient care practices, environmental surveillance, blood collection simulation experiments, and phylogenetic study of HCV strains using partial envelope gene sequences (E1-E2) of HCV genotype 6a strains from the suspected source patient, the environment, and the index patient were performed.

RESULTS

Investigations and data review revealed no further cases of HCV genotype 6a infection in the transplant unit. However, a suspected source with a high HCV load was identified. HCV genotype 6a was found in a contaminated reusable blood-collection tube holder with barely visible blood and was identified as the only shared item posing risk of transmission to the index case patient. Also, 14 episodes of sequential blood collection from the source patient and the index case patient were noted on the computerized time log of the laboratory barcoding system during their 13 days of cohospitalization in the liver transplant ward. Disinfection of the tube holders was not performed after use between patients. Blood collection simulation experiments showed that HCV and technetium isotope contaminating the tip of the sleeve capping the sleeved-needle can reflux back from the vacuum-specimen tube side to the patient side.

CONCLUSIONS

A reusable blood-collection tube holder without disinfection between patients can cause a nosocomial HCV infection. Single-use disposable tube holders should be used according to the recommendations by Occupational Safety and Health Administration and World Health Organization.

Germs of thrones - spontaneous decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) in Western Europe: is this myth or reality?

Background

In France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country.

Material and methods

Retrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions.

Results

We included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3).

Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up.

Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974).

We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300).

Conclusions

Our study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.

Proton pump inhibitor use as a risk factor for Enterobacteriaceal infection: a case-control study

BACKGROUND

Gastric acid suppressants increase the risk of gastroenteritis by allowing ingested pathogens to survive passage through the stomach. It is not known whether the same mechanism affects transmission of Enterobacteriaceae. A case-control study was undertaken to answer this question.

AIM

To determine whether use of proton pump inhibitors (PPIs) increases the risk of infection with Enterobacteriaceae in hospital patients.

METHODS

Retrospective case-control study in a teaching hospital in South West England. Cases were 126 patients infected with extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae between April 2014 and March 2015. Use of PPIs, H2 receptor antagonists or antacids at the time of admission or in the preceding six months was compared with 126 demographically matched controls infected with non-ESBL-producing Enterobacteriaceae and 126 uninfected controls, matched by primary diagnosis.

FINDINGS

Sixty-six of 126 ESBL cases, 62 of 126 non-ESBL controls and 34 of 126 uninfected controls were prescribed PPIs on or within six months of admission. Multi-variable logistic regression analysis gave an odds ratio of 3.37 [95% confidence interval (CI) 1.84-6.18] for PPI exposure vs uninfected controls and 1.15 (95% CI 0.68-1.95) for ESBL infection vs non-ESBL infection. H2 receptor antagonists and antacids were not significantly associated with infection.

CONCLUSION

PPI exposure within the previous six months is significantly associated with infection with both ESBL- and non-ESBL-producing bacteria. Reducing inappropriate use of PPIs may be a novel way to reduce transmission, which might reduce antibiotic use and help control antimicrobial resistance.

Role of Hand Hygiene Ambassador and Implementation of Directly Observed Hand Hygiene Among Residents in Residential Care Homes for the Elderly in Hong Kong

OBJECTIVEMultidrug-resistant organisms (MDROs) are increasingly reported in residential care homes for the elderly (RCHEs). We assessed whether implementation of directly observed hand hygiene (DOHH) by hand hygiene ambassadors can reduce environmental contamination with MDROs.METHODSFrom July to August 2017, a cluster-randomized controlled study was conducted at 10 RCHEs (5 intervention versus 5 nonintervention controls), where DOHH was performed at two-hourly intervals during daytime, before meals and medication rounds by a one trained nurse in each intervention RCHE. Environmental contamination by MRDOs, such as methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum β-lactamse (ESBL)-producing Enterobacteriaceae, was evaluated using specimens collected from communal areas at baseline, then twice weekly. The volume of alcohol-based hand rub (ABHR) consumed per resident per week was measured.RESULTSThe overall environmental contamination of communal areas was culture-positive for MRSA in 33 of 100 specimens (33%), CRA in 26 of 100 specimens (26%), and ESBL-producing Enterobacteriaceae in 3 of 100 specimens (3%) in intervention and nonintervention RCHEs at baseline. Serial monitoring of environmental specimens revealed a significant reduction in MRSA (79 of 600 [13.2%] vs 197 of 600 [32.8%]; P<.001) and CRA (56 of 600 [9.3%] vs 94 of 600 [15.7%]; P=.001) contamination in the intervention arm compared with the nonintervention arm during the study period. The volume of ABHR consumed per resident per week was 3 times higher in the intervention arm compared with the baseline (59.3±12.9 mL vs 19.7±12.6 mL; P<.001) and was significantly higher than the nonintervention arm (59.3±12.9 mL vs 23.3±17.2 mL; P=.006).CONCLUSIONSThe direct observation of hand hygiene of residents could reduce environmental contamination by MDROs in RCHEs.Infect Control Hosp Epidemiol 2018;39:571-577.

A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.