Environmental contamination by carbapenem-resistant Enterobacteriaceae

Comparative performance of contact plate metod and swab method for surface microbial contamination on medical fabrics

BACKGROUND

The contact plate method is widely accepted and used in various fields where hygiene and contamination levels are crucial. Evidence regarding the applicability of the contact plate method for sampling fabric microbial contamination levels in real medical environments was limited. This study aimed to assess the applicability of the contact plate method for detecting microbial contamination on medical fabrics in a real healthcare environment, thereby providing a benchmark for fabric microbial sampling methods.

METHODS

In a level three obstetrics ward of a hospital, twenty-four privacy curtains adjacent to patient beds were selected for this study. The contact plate and swab method were used to collect microbial samples from the privacy curtains on the 1st, 7th, 14th, and 28th days after they were hung. The total colony count on each privacy curtain surface was calculated, and microbial identification was performed.

RESULTS

After excluding the effects of time, room type, and curtain location on the detected microbial load, the linear mixed-effects model analysis showed that contact plate method yielded lower colony counts compared to swab method (P < 0.001). However, the contact plate method isolated more microbial species than swab method (P < 0.001). 291 pathogenic strains were isolated using the contact plate method and 133 pathogenic strains were isolated via the swab method. There was no difference between the two sampling methods in the detection of gram-negative bacteria (P = 0.089). Furthermore, the microbial load on curtains in double-occupancy rooms was lower than those in triple-occupancy rooms (P = 0.021), and the microbial load on curtains near windows was lower than that near doors (P = 0.004).

CONCLUSION

Contact plate method is superior to swab method in strain isolation. Swab method is more suitable for evaluating the bacterial contamination of fabrics.

Hygiene requirements for cleaning and disinfection of surfaces: recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute

This recommendation of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) addresses not only hospitals, but also outpatient health care facilities and compiles current evidence. The following criteria are the basis for the indications for cleaning and disinfection: Infectious bioburden and tenacity of potential pathogens on surfaces and their transmission routes, influence of disinfecting surface cleaning on the rate of nosocomial infections, interruption of cross infections due to multidrug-resistant organisms, and outbreak control by disinfecting cleaning within bundles. The criteria for the selection of disinfectants are determined by the requirements for effectiveness, the efficacy spectrum, the compatibility for humans and the environment, as well as the risk potential for the development of tolerance and resistance. Detailed instructions on the organization and implementation of cleaning and disinfection measures, including structural and equipment requirements, serve as the basis for their implementation. Since the agents for surface disinfection and disinfecting surface cleaning have been classified as biocides in Europe since 2013, the regulatory consequences are explained. As possible addition to surface disinfection, probiotic cleaning, is pointed out. In an informative appendix (only in German), the pathogen characteristics for their acquisition of surfaces, such as tenacity, infectious dose and biofilm formation, and the toxicological and ecotoxicological characteristics of microbicidal agents as the basis for their selection are explained, and methods for the evaluation of the resulting quality of cleaning or disinfecting surface cleaning are presented.

Multidrug-resistant and carbapenemase-producing critical gram-negative bacteria isolated from the intensive care unit environment in Amhara region, Ethiopia

BACKGROUND

Intensive care units are units where healthcare-associated infections (HAIs) are common and antimicrobial resistance rates are increasing. Microbial contamination in hospital environment plays an important role in the development of HAIs. Intervention-based improvements in infection prevention and control at national and facility level are critical for the containment of antimicrobial resistance and prevention of HAIs.

OBJECTIVES

This study aimed to determine the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria (Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Acinetobacter species) and their antibiotic resistance in intensive care unit environmental surfaces at the University of Gondar and Felege Hiwot Comprehensive Specialized Hospitals.

METHODS

This was multicenter hospital-based cross sectional study. Environmental samples were swabbed from all intensive care units using a normal saline moistened-sterile cotton tip stick. Bacteria culturing and antibiotic susceptibility testing were performed following standard microbiological techniques. Selected meropenem-resistant isolates were phenotypically assessed for carbapenemase production using modified and simplified carbapenem inactivation methods.

RESULTS

From a total of 384 environmental samples analyzed, 126 (32.8%) showed growth and 162 isolates were identified. K. pneumoniae (79/162, 48.8%) was the commonest isolate followed by Acinetobacter species (51/162, 31.5%), E. coli (19/162, 11.7%) and P. aeruginosa (13/162, 8.0%). Multidrug-resistant and carbapenemase-producing isolates were detected on most hospital environment surface types, especially from the baby bed sets and incubators. The most common multidrug-resistant and principal carbapenemase producer was K. pneumoniae, with rates of 71(89.9%) and 24(85.7%), respectively.

CONCLUSION

This study revealed the distribution of multidrug-resistant and carbapenemase-producing critical gram negative bacteria in the environment of intensive care unit. Higher detection rate of multidrug-resistant and carbapenemase-producing K. pneumoniae on most environmental surfaces calls for urgent control action and further attention.

Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Potential sources of contamination on textiles and hard surfaces identified as high-touch sites near the patient environment

The hospital environment represents an important mediator for the transmission of healthcare-associated infections through direct and indirect hand contact with hard surfaces and textiles. In this study, bacteria on high-touch sites, including textiles and hard surfaces in two care wards in Sweden, were identified using microbiological culture methods and 16S rDNA sequencing. During a cross-sectional study, 176 high-touch hard surfaces and textiles were identified and further analysed using microbiological culture for quantification of total aerobic bacteria, Staphylococcus aureus, Clostridium difficile and Enterobacteriacae. The bacterial population structures were further analysed in 26 samples using 16S rDNA sequencing. The study showed a higher frequency of unique direct hand-textile contacts (36 per hour), compared to hard surfaces (2.2 per hour). Hard surfaces met the recommended standard of ≤ 5 CFU/cm2 for aerobic bacteria and ≤ 1 CFU/cm2 for S. aureus (53% and 35%, respectively) to a higher extent compared to textiles (19% and 30%, respectively) (P = 0.0488). The number of bacterial genera was higher on textiles than on the hard surfaces. Staphylococcus (30.4%) and Corynebacterium (10.9%) were the most representative genera for textiles and Streptococcus (13.3%) for hard surfaces. The fact that a big percentage of the textiles did not fulfil the criteria for cleanliness, combined with the higher bacterial diversity, compared to hard surfaces, are indicators that textiles were bacterial reservoirs and potential risk vectors for bacterial transmission. However, since most of the bacteria found in the study belonged to the normal flora, it was not possible to draw conclusions of textiles and hard surfaces as sources of healthcare associated infections.

Limiting the Spread of Multidrug-Resistant Bacteria in Low-to-Middle-Income Countries: One Size Does Not Fit All

The spread of multidrug-resistant organisms (MDRO) is associated with additional costs as well as higher morbidity and mortality rates. Risk factors related to the spread of MDRO can be classified into four categories: bacterial, host-related, organizational, and epidemiological. Faced with the severity of the MDRO predicament and its individual and collective consequences, many scientific societies have developed recommendations to help healthcare teams control the spread of MDROs. These international recommendations include a series of control measures based on surveillance cultures and the application of barrier measures, ranging from patients' being isolated in single rooms, to the reinforcement of hand hygiene and implementation of additional contact precautions, to the cohorting of colonized patients in a dedicated unit with or without a dedicated staff. In addition, most policies include the application of an antimicrobial stewardship program. Applying international policies to control the spread of MDROs presents several challenges, particularly in low-to-middle-income countries (LMICs). Through a review of the literature, this work evaluates the real risks of dissemination linked to MDROs and proposes an alternative policy that caters to the means of LMICs. Indeed, sufficient evidence exists to support the theory that high compliance with hand hygiene and antimicrobial stewardship reduces the risk of MDRO transmission. LMICs would therefore be better off adopting such low-cost policies without necessarily having to implement costly isolation protocols or impose additional contact precautions.

Prevalence and incidence of carbapenem-resistant K. pneumoniae colonization: systematic review and meta-analysis

BACKGROUND

Klebsiella pneumoniae is a gram-negative rod belonging to the order Enterobacterales and having a wide distribution in the environment, including the human colon. Recently, the bacterium is one of the known problems in the healthcare setting as it has become resistant to last-resort drugs like carbapenems. The colonized person can serve as a reservoir for his/herself and others, especially in the healthcare setting leading to nosocomial and opportunistic infections. Therefore, we aimed to quantitatively estimate the rate of prevalence and incidence of colonization with carbapenem-resistant K. pneumoniae.

METHODS

A literature search was conducted on PubMed/MEDLINE, Google Scholar, Science Direct, Cochrane Library, WHO Index Medicus, and university databases. The study includes all published and unpublished papers that addressed the prevalence or incidence of K. pneumoniae colonization. Data were extracted onto format in Microsoft Excel and pooled estimates with a 95% confidence interval calculated using Der-Simonian-Laird random-effects model. With the use of I² statistics and prediction intervals, the level of heterogeneity was displayed. Egger's tests and funnel plots of standard error were used to demonstrate the publication bias.

RESULTS

A total of 35 studies were included in the review and 32 records with 37,661 patients for assessment of prevalence, while ten studies with 3643 patients for incidence of colonization. The prevalence of carbapenem-resistant K. pneumoniae colonization varies by location and ranges from 0.13 to 22%, with a pooled prevalence of 5.43%. (3.73-7.42). Whereas the incidence of colonization ranges from 2 to 73% with a pooled incidence of 22.3% (CI 12.74-31.87), both prevalence and incidence reports are majorly from developed countries. There was a variation in the distribution of carbapenem resistance genes among colonizing isolates with KPC as a prominent gene reported from many studies and NDM being reported mainly by studies from Asian countries. A univariate meta-regression analysis indicated continent, patient type, study design, and admission ward do not affect the heterogeneity (p value>0.05).

CONCLUSION

The review revealed that colonization with K. pneumoniae is higher in a healthcare setting with variable distribution in different localities, and resistance genes for carbapenem drugs also have unstable distribution in different geographic areas.

Calcium Potentiated Carbapenem Effectiveness Against Resistant Enterobacter Species

BACKGROUND

Antimicrobial resistance (AMR) remains a global health challenge, as bacteria display increasing resistance to last-resort antibiotics such as carbapenems. Enterobacter cloacae are evolving and developing high level of resistance to carbapenems. With increasing AMR, availability of antibiotics for treatment dwindles, hence a need to complement antibiotics to enhance activity or reduce the level of resistance. This study explored the use of calcium ions in attenuating bacterial resistance to carbapenems.

METHOD

E. cloacae strains isolated from hospital fomites and air were subjected to antimicrobial susceptibility testing with carbapenem antibiotics (imipenem, meropenem, doripenem and ertapenem) using the disc diffusion (E. coli ATCC 25922 as control). Growth profile, Ca-Adjusted assay and time-kill curve of the strains was determined in the presence and absence of carbapenem antibiotics following a calcium stress assay.

RESULTS

Growth profile showed that all the E. cloacae strains grew markedly well at 37°C relative to ATCC 25922 and all strains displayed 80% to 100% level of resistance to tested antibiotics. The growth rate of the strains in the presence of the antibiotics was comparable to the growth rate in the absence of carbapenems. Conditional growth stress with calcium ions showed a 50% reduction in the level of resistance with doripenem displaying the lowest level of reduction and ertapenem, the highest.

DISCUSSION

The study showed that E. cloacae strains displayed high levels of resistance to carbapenems, increasing the possibility of treatment failure. Challenging strains with calcium prior to antibiotic treatment led to a significant reduction in level of resistance, indicating that calcium ions could affect bacterial strains during antibiotic activity leading to reduction in level of resistance.

CONCLUSION

Calcium supplement could potentiate carbapenem effectiveness and reduce bacterial AMR.

In vitro activity of six biocides against carbapenemase-producing Klebsiella pneumoniae and presence of genes encoding efflux pumps

INTRODUCTION

Acquisition of reduced susceptibility to biocides may contribute to the dissemination of high-risk (HR) clones of carbapenemase-producing Klebsiella pneumoniae (CP-Kp). The aim of this study was (a) to determinate the activity of biocides against CP-Kp, and (b) to analyse the relationship between biocide activity and the presence of efflux pumps.

METHODS

The minimal inhibitory concentrations (MICs) of 6 biocides (sodium hypochlorite, chlorhexidine digluconate, benzalkonium chloride, povidone-iodine, ethanol and triclosan) were determined in triplicate at 25°C and 37°C in Mueller-Hinton broth (MHB) and M9 minimum medium, against 17 CP-Kp isolates representing different clones (HR and no-HR), sequence-types (STs) and carbapenemases. Efflux pumps genes were detected by whole genome sequencing (MiSeq).

RESULTS

Median MICs were slightly higher at 37°C than at 25°C (p≤0.05), except for benzalkonium chloride, triclosan and ethanol. MIC medians were much higher in MHB than in M9, except for triclosan. No significant differences were observed in the median MICs, regarding the type of clone, ST or carbapenemase; cepA, acrAB, kpnEF and oqxAB genes were detected in all isolates, whereas qacE and qacA were not detected; smvAR, and qacΔE genes were detected in 94% and 47% of isolates, respectively.

CONCLUSIONS

Triclosan, chlorhexidine digluconate, benzalkonium chloride and ethanol were the most active biocides. The activity of some biocides is affected by temperature and growth media, suggesting that standardised procedures for biocide susceptibility testing based on MIC determination are required. This activity, in terms of MICs, are not related to the type of clone, ST, carbapenemase or the presence of the efflux pump genes.

Carbapenemase producing Enterobacteriaceae: Environmental reservoirs as primary targets for control and prevention strategies

Carbapenemase-producing Enterobacteriaceae (CPE) have become one of the greatest public health challenges globally. In the past decade, antimicrobial resistance (AMR) was viewed as a clinical problem in many parts of the world; hence, the role and magnitude of the contribution of the environment were not well appreciated. This review article was done with online published articles extracted from different databases using search terms related to the work. Evidence has shown that there exists the presence of carbapenemase genes in the environment, consequently fuelling the dissemination with alarming consequences. CPE when acquired causes life-threatening infections in humans. The health and economic impact of these infections are numerous, including treatment failure due to limited therapeutic options which hamper the containment of infectious diseases, further contaminating the environment and worsening the public health challenge. It is a well-known fact that the rate of emergence of resistant genes has outpaced the production of new antimicrobial agents, so it is pertinent to institute effective environmental measures to combat the spread of AMR organisms before it will completely gain a foothold and take us back to 'the pre-antibiotic era'. Environmental sources and reservoirs of resistant genes should therefore be amongst the primary targets for the control and prevention of the spread of resistant genes in the environment. This calls for the effective implementation of the 'one health' strategy with stakeholders committed to the design and enforcement of environmental mitigation policies and guidelines.

Molecular Characterization of Carbapenem-Resistant Acinetobacter baumannii Isolates Among Intensive Care Unit Patients and Environment

Objective

Methods

Results

Conclusion

Predominance of Acinetobacter spp., Harboring the blaIMP Gene, Contaminating the Hospital Environment in a Tertiary Hospital in Mwanza, Tanzania: A Cross-Sectional Laboratory-Based Study

Data on colonization and hospital contamination of carbapenem-resistant Gram-negative bacteria (CR-GNB) are limited in low- and middle-income countries. We designed this study to determine the prevalence and co-existence of carbapenemase genes among CR-GNB isolated from clinical, colonization, and hospital environmental samples at a tertiary hospital in Mwanza, Tanzania. The modified Hodge test (MHT), the combined disk test (CDT), and the double-disk synergy test (DDST) were used for the phenotypic detection of carbapenemases. A multiplex PCR assay was used to detect bla_IMP and bla_KPC, and a singleplex PCR assay was used to detect bla_OXA-48. Data were analyzed by STATA version 13.0. Overall, 68.8% (44/64) of the CR-GNB had at least one phenotype by phenotypic methods, whereby 60.9% (39/64) were both CDT and DDST positive and 31.3% (20/64) were MHT positive. A total of 23/64 (35.9%) had at least one of the genes tested with the predominance of bla_IMP (91.3%; 21/23). In addition, 47.7% (21/44) of the CR-GNB phenotypes had at least one gene. Around 47.8% (11/23) of the CR-GNB carried multiple genes encoding for carbapenem resistance, with the maximum co-existence of bla_IMP/bla_KPC/bla_OXA-48 (45.5%; 5/11). The majority of carbapenem-resistant genes were detected in Acinetobacter spp. (82.6%; 19/23) and isolated from bed swabs (69.6%; 16/23). Acinetobacter spp. carrying the bla_IMP gene predominantly contaminated the hospital environment. Therefore, we recommend routine decontamination of inanimate hospital surfaces, including patient beds.

Direct-PCR from rectal swabs and environmental reservoirs: A fast and efficient alternative to detect blaOXA-48 carbapenemase genes in an Enterobacter cloacae outbreak setting

Carbapenemase-producing bacteria are a risk factor in clinical settings worldwide. The aim of the study was to accelerate the time to results during an outbreak situation with bla_OXA-48-positive Enterobacter cloacae by using a real-time multiplex quantitative PCR (qPCR) directly on rectal swab specimens and on wastewater samples to detect carbapenemase-producing bacteria. Thus, we analyzed 681 rectal swabs and 947 environmental samples during a five-month period by qPCR and compared the results to culture screening. The qPCR showed a sensitivity of 100% by testing directly from rectal swabs and was in ten cases more sensitive than the culture-based methods. Environmental screening for bla_OXA-48-carbapenemase genes by qPCR revealed reservoirs of different carbapenemase genes that are potential sources of transmission and might lead to new outbreaks. The rapid identification of patients colonized with those isolates and screening of the hospital environment is essential for earlier patient treatment and eliminating potential sources of nosocomial infections.

The novel application and effect of an ultraviolet light decontamination strategy on the healthcare acquisition of carbapenem-resistant Enterobacterales in a hospital setting

BACKGROUND

The role of the hospital environment as contributory to healthcare acquisition of multidrug resistant organisms (MDRO) is increasingly recognised. Ultraviolet light decontamination can minimise the environmental bioburden thereby potentially reducing healthcare-acquisition. This effect has been demonstrated for typical environmental MDRO e.g. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Clostridioides difficile however, its role in reducing carbapenem resistant Enterobacterales (CRE) incidence rates is unclear.

AIM

To evaluate the impact of continuous ultraviolet light (C-UV) on healthcare acquisition rates of CRE.

METHODS

We conducted a 26-month pragmatic, prospective interventional study with addition of C-UV decontamination to standard cleaning in units at high risk for CRE acquisition. Introduction of C-UV followed a 12 month baseline period, with a 2 month wash-in period. Implementation included terminal decontamination at discharge and a novel in-use protocol, whereby rooms occupied for 48 hours and longer were decontaminated during the course of the patients in-hospital stay. Incidence density rates of CRE during the intervention period were compared to the baseline period using interrupted time series regression. Rates were adjusted for ward/admission prevalence and analysed according to C-UV protocol.

FINDINGS

The in-use C-UV protocol demonstrated a significant negative association with the incidence density rate of CRE when adjusting for CRE admission rate (p = 0.0069). CRE incidence density rates decreased significantly during the intervention period (P = 0.042). Non-intervention units demonstrated no change in incidence density rates when adjusting for ward and/or admission prevalence.

CONCLUSION

C-UV decontamination can potentially reduce healthcare acquisition of CRE when implemented with an in-use protocol.

Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update

Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.

Determination of genetic relationship between environmental Escherichia coli with PFGE and investigation of IS element in blaCTX-M gene of these isolates

INTRODUCTION

ESBL producing Escherichia coli (E. coli) have spread in the hospital settings. The aims of this study determination of genetic relationship between Environmental E. coli with PFGE typing and investigation of IS element in bla_CTX-M gene of these isolates.

MATERIALS AND METHODS

A total of 50 E. coli isolates were collected from hospital environmental. The bla_CTX-M producing E. coli and IS element of this gene with phylogenetic typing were detected by PCR. The PFGE was performed to detect genetic relationships between this strains.

RESULTS

Most of the isolates were from urology wards, other samples were isolated from ICU, surgery and orthopedic ward. The majority of isolates were resistant to cefotaxime and ceftazidime antibiotics and also phosphomycin antibiotic resistant were detected in 10% of isolates. CTX-M gene was detected in 72% of isolates. Moreover, ISEcp1, IS26a, and IS26b were detected upstream of CTX-M in 24%, 8% and 16 of isolates. A phylogroup was the most frequent and PFGE analysis exhibited a diverse distribution of E. coli isolates.

CONCLUSIONS

The results demonstrated the existence of CTX-M-producing E. coli in a hospital environment which is a source for drug-resistant strains. In the most of strains, ISEcp1 was located in the upstream of CTX-M gene and Orf477 was found in the downstream. However, in some strains, IS26 was inserted within the ISEcp1element. Our results show that despite the fact that antibiotics of phosphomycin are not used in this hospital, resistance to phosphomycin was observed in the environmental E. coli.

Spread of Carbapenem-Resistant Klebsiella pneumoniae in an Intensive Care Unit: A Whole-Genome Sequence-Based Prospective Observational Study

The aim of this study was to determine the contribution of the contamination of the health care environment in the acquisition of carbapenem-resistant Klebsiella pneumoniae (CRKP) in a CRKP-prevalent setting. We performed a 3-month prospective study in a 20-bed medical intensive care unit (ICU) by collecting rectal/oral swabs from patients within 3 days of ICU admission and weekly thereafter. We also comprehensively sampled the beds and rooms of patients and instruments for patient care every week. CRKP were detected, genome sequenced, and assigned to clones based on core genome analyses. The survival of four CRKP clones was determined under ICU conditions. Seventeen patients were in the ICU at the start of the study, and 99 were admitted afterwards. Six were positive patients, with four detected on initial screening and two during weekly monitoring. CRKP was detected from 76 of 3,699 (2.1%) environment samples, including from the immediate surroundings of 21 patients (five had CRKP from clinical samples and 16 did not). CRKP was not detected outside patient care areas. Among 49 CRKP sequenced isolates (nine from swabs, five from clinical samples, and 35 from environment) from 21 patients, 45 were ST11 and had bla_KPC-2. These could be assigned to four clones, with either KL47 (n = 22) or KL64 (n = 23) capsular type. The two dominant clones survived >30 days under ICU conditions. In conclusion, environmental contamination of CRKP was extensive but usually transient. It had little impact on CRKP acquisition by ICU patients, highlighting the ability to control CRKP transmission through infection prevention efforts even in high-prevalence settings.

IMPORTANCEKlebsiella pneumoniae can be an opportunistic pathogen with the oral cavity and gut the main origin. However, carbapenem-resistant Klebsiella pneumoniae (CRKP) can be found in patient surroundings and is a serious threat for human infections. Although the hospital environment, particularly sinks, has long been considered a potential reservoir of CRKP, the exact role of environmental contamination contributing to the acquisition and transmission of CRKP among patients remains largely unknown. To understand the link between environmental contamination in health care settings and colonization and infection of patients by CRKP, we performed a 3-month prospective study in a 20-bed medical ICU. Isolates were collected by active patient screening and were subsequently genome sequenced to describe the diversity of CRKP and the linkage of patients and environmental reservoirs. We found that the environmental contamination of CRKP was extensive, and CRKP clones were freely circulating in the ICU. Environmental contamination was not due to sharing the bed unit or sharing contaminated instruments but more likely resulted from the movement of health care workers. Very few patients acquired CRKP in the ICU, which is likely due to the fact that environmental contamination was usually transient when a routine cleaning protocol was complied. Although CRKP contamination in patient surroundings may be extensive, as long as routine environment cleaning protocols are appropriate and well implemented, the health care environment is unlikely to be a major source of CRKP colonization and infection in ICU patients. Reducing the high workload for ICU nurses may help minimize CRKP environmental contamination.

In vitro activity of six biocides against carbapenemase-producing Klebsiella pneumoniae and presence of genes encoding efflux pumps

INTRODUCTION

Acquisition of reduced susceptibility to biocides may contribute to the dissemination of high-risk (HR) clones of carbapenemase-producing Klebsiella pneumoniae (CP-Kp). The aim of this study was (a) to determinate the activity of biocides against CP-Kp, and (b) to analyse the relationship between biocide activity and the presence of efflux pumps.

METHODS

The minimal inhibitory concentrations (MICs) of 6 biocides (sodium hypochlorite, chlorhexidine digluconate, benzalkonium chloride, povidone-iodine, ethanol and triclosan) were determined in triplicate at 25°C and 37°C in Mueller-Hinton broth (MHB) and M9 minimum medium, against 17 CP-Kp isolates representing different clones (HR and no-HR), sequence-types (STs) and carbapenemases. Efflux pumps genes were detected by whole genome sequencing (MiSeq).

RESULTS

Median MICs were slightly higher at 37°C than at 25°C (p≤0.05), except for benzalkonium chloride, triclosan and ethanol. MIC medians were much higher in MHB than in M9, except for triclosan. No significant differences were observed in the median MICs, regarding the type of clone, ST or carbapenemase; cepA, acrAB, kpnEF and oqxAB genes were detected in all isolates, whereas qacE and qacA were not detected; smvAR, and qacΔE genes were detected in 94%and 47% of isolates, respectively.

CONCLUSIONS

Triclosan, chlorhexidine digluconate, benzalkonium chloride and ethanol were the most active biocides. The activity of some biocides is affected by temperature and growth media, suggesting that standardised procedures for biocide susceptibility testing based on MIC determination are required. This activity, in terms of MICs, are not related to the type of clone, ST, carbapenemase or the presence of the efflux pump genes.

Frequency of surface bacterial contamination in family physicians' offices

OBJECTIVES

The environment is perceived as a potential source of healthcare-associated infections. While this infection source has been well studied in hospital settings, little data on the risk of contamination in general medical practice is available. We aimed to assess the frequency of environmental contamination in family practice (FP), and to describe pathogens isolated, at-risk surfaces, and factors associated with this contamination.

PATIENTS AND METHODS

We conducted a cross-sectional point prevalence study over six months in 51 FP offices. In each office, six environmental samples were collected after and before consultations on high-touch surfaces (stethoscope, examination table, physician's desktop, blood pressure cuff, medical equipment tray, computer keyboard and mouse).

RESULTS

A total of 580 samples were obtained. All offices were contaminated at any time with at least 2.5 colony forming units. The median rate of examination room bio-cleaning was twice a week. For all equipment and surfaces, a lower bacterial load was found before consultations when the last cleaning had occurred less than 24hours prior to testing.

CONCLUSION

High environmental contamination was observed in FP offices. Less than one practice in five used an effective cleaning agent; family physicians' awareness of practice hygiene is an important step for prevention.

Positive correlation between Candida auris skin-colonization burden and environmental contamination at a ventilator-capable skilled nursing facility in Chicago

BACKGROUND

Candida auris is an emerging multidrug-resistant yeast that contaminates healthcare environments causing healthcare-associated outbreaks. The mechanisms facilitating contamination are not established.

METHODS

C. auris was quantified in residents' bilateral axillary/inguinal composite skin swabs and environmental samples during a point-prevalence survey at a ventilator-capable skilled-nursing facility (vSNF A) with documented high colonization prevalence. Environmental samples were collected from all doorknobs, windowsills and handrails of each bed in 12 rooms. C. auris concentrations were measured using culture and C. auris-specific qPCR. The relationship between C. auris concentrations in residents' swabs and associated environmental samples were evaluated using Kendall's tau-b (τb) correlation coefficient.

RESULTS

C. auris was detected in 70 /100 tested environmental samples and 31/ 57 tested resident skin swabs. The mean C. auris concentration in skin swabs was 1.22 x 10 5 cells/mL by culture and 1.08 x 10 6 cells/mL by qPCR. C. auris was detected on all handrails of beds occupied by colonized residents, as well as 10/24 doorknobs and 9/12 windowsills. A positive correlation was identified between the concentrations of C. auris in skin swabs and associated handrail samples based on culture (τb = 0.54, p = 0.0004) and qPCR (τb = 0.66, p = 3.83e -6). Two uncolonized residents resided in beds contaminated with C. auris.

CONCLUSIONS

Colonized residents can have high C. auris burdens on their skin, which was positively related with contamination of their surrounding healthcare environment. These findings underscore the importance of hand hygiene, transmission-based precautions, and particularly environmental disinfection in preventing spread in healthcare facilities.

Risk factors for the environmental spread of different multidrug-resistant organisms: a prospective cohort study

BACKGROUND

Substantial scientific evidence shows that contamination of environmental surfaces in hospitals plays an important role in the transmission of multidrug-resistant organisms (MDROs). To date, studies have failed to identify the risk factors associated with environmental contamination.

AIM

To evaluate, compare, and identify factors associated with environmental contamination around carriers of different MDROs.

METHODS

This was a prospective cohort study from May 2018 to February 2020. A total of 125 patients were included, having been admitted to Avicenne Hospital and Hotel Dieu de France de Beyrouth Hospital who were faecal carriers of MDROs (extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE)). For each patient, quantification of MDRO in stool was undertaken, plus a qualitative evaluation of the presence of MDRO in six different environmental sites; and clinical data were collected.

FINDINGS

MDROs comprised ESBL-PE (34%), CPE (45%), and VRE (21%). The most frequent MDRO species was Escherichia coli. Contamination of at least one environmental site was observed for 22 (18%) patients. Only carriage of VanA was associated with a significantly higher risk of dissemination. Having a urinary catheter, carriage of OXA48 and E. coli were protective factors against environmental contamination. There were no significant differences in environmental contamination between E. coli and other Enterobacterales or between ESBL-PE and CPE.

CONCLUSIONS

Hospital environmental contamination rates are substantially higher for patients with VRE, compared to the low environment dissemination rates around ESBL-PE and CPE. Further studies on a larger scale are needed to confirm the validity of our findings.

Prevalence of carbapenem-resistant Enterobacteriaceae and emergence of high rectal colonization rates of blaOXA-181-positive isolates in patients admitted to two major hospital intensive care units in Kuwait

BACKGROUND

Fecal colonization by carbapenem-resistant Enterobacteriaceae (CRE) can be the main reservoir for transmission of these resistant organisms especially in the Intensive Care Units (ICUs).

AIM

This study was conducted to evaluate the rate of rectal carriage and molecular characterization of CRE in patients hospitalized in the ICUs of 2 major hospitals (Adan and Mubarak Al Kabeer Hospitals) in Kuwait.

MATERIALS AND METHODS

Rectal swabs were collected from all patients at admission, 48 h after admission and once weekly from April 2017- March 2018. Initial CRE screening was carried out on MacConkey agar on which meropenem disc 10μg was placed. Identification of isolates was by API 20E. Susceptibility testing was performed using the E-test method. Polymerase chain reaction (PCR) was used to detect the carbapenemase-encoding genes. Clonal relationship was investigated by pulsed-field electrophoresis (PFGE). Genes of blaOXA-181 and blaNDM-5-carrying plasmids were detected in some strains.

RESULTS

A total of 590 patients were recruited into the study. Of these, 58 were positive for CRE, giving a prevalence of 9.8%; 25/320 (7.8%) in Adan and 33/270 (12.2%) in Mubarak Al Kabeer Hospitals. All isolates were resistant to multiple antibiotics. Resistance rates to colistin and tigecycline were 17% and 83%, respectively. Single genes of blaOXA-181 were detected in isolates from 38 (65.5%) out of 58 patients and in 5 patients colonized by blaOXA-48-positive CRE. A combination of 2 genes was detected in 12 isolates; 5 blaKPC-2 and blaOXA-181, 4 blaVIM-1 and blaOXA-181, and 3 blaNDM-5 and blaOXA-181. PFGE showed an overall level of similarity of 38%. Southern hybridization studies localized the blaOXA-181 and blaNDM-5 genes to a large plasmid of 200kb in 3 K. pneumoniae isolates and a small plasmid of 80kb in 2 E. coli isolates, respectively.

CONCLUSION

The prevalence of CRE colonization in the 2 hospital ICUs was relatively high and the emergence of blaOXA-181-mediated CRE is a cause for concern as there is the possibility of rapid horizontal spread among hospital patients in Kuwait. Active surveillance of CRE in the ICUs is highly recommended to stem its spread.

Molecular Epidemiology of Carbapenemases in Enterobacteriales from Humans, Animals, Food and the Environment

The Enterobacteriales order consists of seven families including Enterobacteriaceae, Erwiniaceae, Pectobacteriaceae, Yersiniaceae, Hafniaceae, Morganellaceae, and Budviciaceae and 60 genera encompassing over 250 species. The Enterobacteriaceae is currently considered as the most taxonomically diverse among all seven recognized families. The emergence of carbapenem resistance (CR) in Enterobacteriaceae caused by hydrolytic enzymes called carbapenemases has become a major concern worldwide. Carbapenem-resistant Enterobacteriaceae (CRE) isolates have been reported not only in nosocomial and community-acquired pathogens but also in food-producing animals, companion animals, and the environment. The reported carbapenemases in Enterobacteriaceae from different sources belong to the Ambler class A (bla_KPC), class B (bla_IMP, bla_VIM, bla_NDM), and class D (bla_OXA-48) β-lactamases. The carbapenem encoding genes are often located on plasmids or associated with various mobile genetic elements (MGEs) like transposons and integrons, which contribute significantly to their spread. These genes are most of the time associated with other antimicrobial resistance genes such as other β-lactamases, as well as aminoglycosides and fluoroquinolones resistance genes leading to multidrug resistance phenotypes. Control strategies to prevent infections due to CRE and their dissemination in human, animal and food have become necessary. Several factors involved in the emergence of CRE have been described. This review mainly focuses on the molecular epidemiology of carbapenemases in members of Enterobacteriaceae family from humans, animals, food and the environment.

Risk of hospital readmission and associated factors after a positive sample for a multidrug-resistant microorganism

BACKGROUND

To determine the risk of hospital readmission and associated factors in patients with a positive sample for multidrug-resistant microorganisms (MRM) and to analyze whether there is a higher risk of hospital readmission with some of the more common MRM.

METHODS

Retrospective cohort study (2012-16) performed in a tertiary-care teaching hospital in Barcelona. Patients were divided into two groups, depending on the presence or absence of an MRM-positive sample during hospital admission. Logistic regression models were used to estimate the risk of hospital readmission in the first 30 and 90 days, and the first year for patients with an MRM-positive sample compared with those without. The models were stratified by the presence or absence of an MRM-positive sample and by grouped Charlson comorbidity index.

RESULTS

We included 983 patients with an MRM-positive sample and 39 323 patients without. The risk of hospital readmission in the first 30 days was 41% higher in admitted patients with an MRM-positive sample (95%CI=1.17 to 1.69) than in those without. Stratified models showed similar results to the overall results for all Charlson comorbidity index groups. When the models were stratified by the presence of an MRM-positive sample, methicillin-resistant Staphylococcus aureus showed the highest risk of readmissions within the more common MRM [103% (95%CI=1.10 to 3.75)].

CONCLUSION

MRMs seem to be an important risk factor for hospital readmissions both among patients with and without comorbidities. Specific types of MRM may represent a higher risk for hospital readmissions than other MRMs, depending on the particular environment or hospital.

Epidemic Characteristics of Carbapenem-Resistant Klebsiella pneumoniae in the Pediatric Intensive Care Unit of Yanbian University Hospital, China

Introduction

Carbapenem-resistant Enterobacteriaceae (CRE) pose a serious threat to clinical patient management and public health, as they are generally resistant to most antibiotics and cause infections with high mortality rates. Klebsiella pneumoniae ranks second among Enterobacteriaceae species that cause nosocomial infections. In this study, we investigated the epidemic characteristics of carbapenem-resistant K. pneumoniae (CRKP) in the pediatric intensive care unit (PICU) of Yanbian University Hospital.

Materials and Methods

A total of 14 non-duplicate CRKP strains, collected from March 2015 to November 2019, were subjected to automated microbial identification and antimicrobial susceptibility tests using the Phoenix-100 ID/AST system. The strains were also subjected to genotypic resistance testing, polymerase chain reaction assays to detect genes encoding carbapenemases and other β-lactamases, multi-locus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE)-based homology analysis.

Results

Two carbapenemase genes, KPC-2 and NDM-1 (in eight and six strains, respectively), were detected. MLST enabled the division of the strains into two sequence types, ST11 and ST1224 (containing eight and six strains, respectively). PFGE results classified the 14 strains into clonotypes A–D, of which clonotypes A and B belonged to ST11, while clonotypes C and D belonged to ST1224.

Conclusion

Our study reveals that epidemics of the KPC-2-ST11 and NDM-1-ST1224 strains occurred in the PICU of Yanbian University Hospital. Surveillance and strict implementation of prevention and control measures are crucial to prevent the occurrence and rapid spread of nosocomial infections.

Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory?

BACKGROUND

Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination.

AIM/METHODS

We conducted a narrative review of the literature and discussed the role of cohorting.

FINDINGS

CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated.

CONCLUSION

Local epidemiology and resources must be assessed before implementing cohorting.

Can environmental contamination be explained by particular traits associated with patients?

BACKGROUND

Little is known about patient risk factors associated with environmental contamination.

AIM

To evaluate the rate of environmental contamination and to investigate individual risk factors.

METHODS

A prospective cohort study was conducted. Each day, five rooms occupied by patients were selected. Five critical surfaces were systematically swabbed twice a day before and after cleaning. Clinical characteristics of all patients were collected. Logisitic regression was performed to evaluate the association between environmental contamination and patients' characteristics.

FINDINGS

A total of 107 consecutive patients were included and 1052 environmental samples were performed. Nineteen (18%) patients were known previously colonized/infected with a multidrug-resistant organism (MDRO). Respectively, 723 (69%) and 112 (11%) samples grew with ≥1 and >2.5 cfu/cm² bacteria, resulting in 62 (58%) contaminated rooms. Considering positive samples with at least one pathogenic bacterium, 16 (15%) rooms were contaminated. By univariate and multivariate analysis, no variables analysed were associated with the environmental contamination. Considering contaminated rooms with >2.5 cfu/cm², three factors were protective for environmental contamination: known MDRO carriers/infected patients (odds ratio: 0.25; 95% confidence interval: 0.09-0.72; P = 0.01), patients with urinary catheter (0.19; 0.04-0.89; P = 0.03) and hospitalization in single room (0.3; 0.15-0.6; P < 0.001).

CONCLUSION

This study was conducted in a non-outbreak situation and showed a low rate of environmental contamination with pathogenic bacteria. Only 11% of environmental samples grew with >2.5 cfu/cm², and they were related to non-pathogenic bacteria. No risk factors associated with environmental contamination were identified.

A Study on Isolation, Characterization, and Exploration of Multiantibiotic-Resistant Bacteria in the Wound Site of Diabetic Foot Ulcer Patients

This study collected wound swab samples from 50 diabetic patients, especially in Wagner's grade 2 (28) and grade 3 (22) foot ulcers. The samples were processed and subjected to bacterial isolation and characterization. The obtained diabetic foot ulcer (DFU) bacterial isolates were also subjected to antibiotic susceptibility assay. All the collected samples were culture positive and produced a total of 85 isolates. Monomicrobial and polymicrobial infections were observed from the collected grade 2 and 3 samples, respectively. Gram's staining and morphological analyses of the obtained bacterial colony demonstrated the presence of both Gram-positive and Gram-negative bacilli, Gram-positive cocci, and Gram-negative cocco-bacilli in the wounds of diabetic patients. The bacterial profiling of 85 isolates revealed the presence of Gram-negative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Proteus spp, Acinetobacter spp, Enterobacter spp, Klebsiella pneumoniae, Citrobacter spp, K oxytoca, and Stenotrophomonas spp Gram-positive bacteria such as Staphylococcus aureus, Bacillus subtilis, Enterococcus faecalis, Corynebacterium spp, and Streptococcus dysgalactiae were also identified. The predominant microbial flora found in the collected samples were Staphylococcus aureus (38%) and P aeruginosa (23.2%), followed by B subtilis (21%) and Escherichia coli (18%) and other bacteria. Furthermore, the obtained antibiotic susceptibility assay data of DFU isolates have also confirmed the distribution of multiantibiotic-resistant bacteria in the wound site of diabetic patients. The findings of the present study suggest that there is a need for the discovery of novel drug(s) to alleviate antibiotic-resistant bacterial infections in DFU patients.

Drug-resistant bacteria on hands of healthcare workers and in the patient area: an environmental survey in Southern Italy's hospital

OBJECTIVE

Drug-resistant bacteria on hands of healthcare workers and in the patient area: an environmental survey in Southern Italy's hospital.

METHODS

The study was conducted from June 2017 to May 2018 using contact slides for surfaces and active sampling for air. We used automated biochemical methods to identify microorganisms; antibiograms were performed in compliance with the EUCAST expert rules.

RESULTS

We analyzed 3,760 samples, 16.17% were found positive and 34 % of these were antimicrobial-resistant. On analyzing the isolated Staphylococci, 39% were multidrug-resistant and 5% extensively drug-resistant. A 30% of the Enterococcus faecalis isolates were resistant to gentamycin and vancomycin. We found Klebsiella pneumoniae isolates resistant to ceftriaxone, cefoxitin, mecillinam and imipenem. A 7% and 8% of the Acinetobacter baumannii and Pseudomonas aeruginosa isolates, respectively, were resistant to gentamicin, imipenem, and ceftazidime.

CONCLUSIONS

These findings are in line with the international literature, confirming that antimicrobial resistance is also steadily growing in Italy with rates varied for the different pathogens.

How to carry out microbiological sampling of healthcare environment surfaces? A review of current evidence

There is increasing evidence that the hospital surface environment contributes to the spread of pathogens. However, evidence on how best to sample these surfaces is inconsistent and there is no guidance or legislation in place on how to do this. The aim of this review was to assess current literature on surface sampling methodologies, including the devices used, processing methods, and the environmental and biological factors that might influence results. Studies published prior to March 2019 were selected using relevant keywords from ScienceDirect, Web of Science, and PubMed. Abstracts were reviewed and all data-based studies in peer-reviewed journals in the English language were included. Microbiological air and water sampling in the hospital environment were not included. Although the numbers of cells or virions recovered from hospital surface environments were generally low, the majority of surfaces sampled were microbiologically contaminated. Of the organisms detected, multidrug-resistant organisms and clinically significant pathogens were frequently isolated and could, therefore, present a risk to vulnerable patients. Great variation was found between methods and the available data were incomplete and incomparable. Available literature on sampling methods demonstrated deficits with potential improvements for future research. Many of the studies included in the review were laboratory-based and not undertaken in the real hospital environment where sampling recoveries could be affected by the many variables present in a clinical environment. It was therefore difficult to draw overall conclusions; however, some recommendations for the design of routine protocols for surface sampling of healthcare environments can be made.

Emergence of NDM-4-producing Klebsiella pneumoniae in a Korean hospital due to a patient hospitalized in Vietnam and case review

NDM-4-producing Klebsiella pneumoniae (NDM-4-KP) was detected from the patient who had previously been injured and hospitalized for 5 days in Vietnam in a neurosurgical intensive care unit (NSICU) of a Korean tertiary-care hospital in December 2016. He admitted with ventilator-associated pneumonia and NDM-4-KP was isolated, which was subsequently detected in two other NSICU patients. All NDM-4-KP isolates from patient and environmental surveillance cultures were sequence type 11. Colonization of three patients persisted for 5-12 months. Dedicated environmental cleaning was added to single room isolation of NDM-4-KP patients and universal chlorhexidine bathing, and no further transmission of NDM-4-KP occurred. This is the first report of NDM-4-KP in a Korean hospital where a patient with a history of hospitalization abroad was the index case initiating an outbreak involving three patients. The spread of newly introduced CPE was controlled using a bundle of infection control.

Prevalence and Risk Factors of Carbapenem-resistant Enterobacteriaceae Acquisition in an Emergency Intensive Care Unit in a Tertiary Hospital in Korea: a Case-Control Study

BACKGROUND

Infections caused by carbapenem-resistant Enterobacteriaceae (CRE) are associated with high mortality rates and their treatment is difficult because treatment is limited to certain antibiotics, such as colistin and tigecycline. We aimed to perform active surveillance culture of CRE (ASC-CRE) to monitor the prevalence of CRE acquisition during intensive care unit (ICU) care and to examine the potential risk factors associated with CRE acquisition.

METHODS

We conducted ASC-CRE on patients who were admitted to the ICU in the emergency room at a tertiary hospital. Rectal swabs were analyzed using methods established by the Centers for Disease Control and Prevention. To detect carbapenemase-producing CRE, a polymerase chain reaction assay to detect five carbapenemase genes (bla_NDM, bla_KPC, bla_VIM, bla_IMP-1, and bla_OXA-48) was performed.

RESULTS

There were 22 CRE acquisition in 21 patients (2.6%, 21/810) and the incidence of CRE acquisition was 4.3/1,000 person-days, respectively. The most common species detected was Klebsiella pneumoniae (72.7%, 16/22), and 9 carbapenemase-producing CREs (7 bla_KPC and 2 bla_NDM) were detected. Independent risk factors associated with CRE acquisition were men gender (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 1.3-21.3), history of admission within one year (aOR, 3.9; 95% CI, 1.2-12.1), co-colonization with multidrug-resistant Acinetobacter baumannii (aOR, 15.6; 95% CI, 3.6-67.8) and extended-spectrum β-lactamases-producing bacteria (aOR, 4.7; 95% CI, 1.5-14.6), and exposure to glycopeptide antibiotics (aOR, 3.6; 95% CI, 1.3-9.9).

CONCLUSION

The identification of patients with risk factors for CRE acquisition and early detection of CRE acquisition using ASC-CRE may be useful for CRE control.

Increased Mortality Among Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae Carriers Who Developed Clinical Isolates of Another Genotype

Background

Carbapenemase production by carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) is encoded by a variety of genes on mobile genetic elements. Patients colonized by 1 genotype of CP-CRE may be subsequently infected by another genotype of CP-CRE. We sought to determine whether CP-CRE carriers who developed infection with another genotype had a higher mortality risk.

Methods

A retrospective cohort study was conducted using collected data from January 2012 to December 2016. Clinical isolates of CP-CRE were analyzed among the CP-CRE carriers who had developed an infection during their stay in the hospital. Comparison was made between CP-CRE carriers who developed clinical isolates of another genotype and those whose clinical isolates were of the same CP-CRE genotype that they were originally colonized with. The primary outcome analyzed was the 14-day mortality rate.

Results

A total of 73 CP-CRE carriers who had developed infection were analyzed. Ten (15.4%) of the carriers who developed an infection with clinical isolates of the same CP-CRE genotype died within 14 days, whereas 5 (62.5%) of those who developed an infection with clinical isolates of a different genotype died. This represented a 6-fold increase (adjusted relative risk, 6.36; 95% confidence interval, 1.75-23.06; P = .005) in the 14-day mortality rate.

Conclusions

CP-CRE carriers who developed clinical isolates of another genotype are at risk of increased mortality. This is a novel finding that is of interest to health care organizations worldwide, with profound implications for infection control measures, such as patient and staff cohorting.

High rate of carbapenem-resistant Klebsiella pneumoniae detected from hospital equipments in Iran

The objective of this study was to assess the prevalence, antibiogram, and related genes of carbapenem-resistant Klebsiella pneumoniae (CRKP) among hospital environment samples. A total of 250 samples were taken from different surfaces and medical devices of three hospitals in Isfahan, Iran. All samples were cultured and K. pneumoniae strains were identified by conventional microbiological methods and polymerase chain reaction (PCR). Antibiogram of isolates was performed by disk diffusion method and production of carbapenemases and metallo-β-lactamases (MBLs) was confirmed using modified Hodge test and E-test, respectively. Molecular detection of the related genes was carried out by PCR. Overall, 37 (14.8%) K. pneumoniae strains were isolated, of which 34 (91.9%) strains were resistant to carbapenems. Twenty-eight (82.4%) isolates were positive for carbapenemases and seven (20.6%) isolates were phenotypically MBL producers. The results of PCR showed that the prevalence of bla_OXA-48, bla_NDM, bla_IMP, bla_SHV, bla_CTX-M, bla_TEM, and class 1 integron among CRKP isolates was 70.6%, 52.9%, 2.9%, 100%, 82.4%, 55.9%, and 76.5%, respectively. However, bla_KPC, bla_GES, bla_IMI, bla_VIM, and class 2 integron were not detected in any of the isolates. This study showed that the environment of our hospitals is contaminated with CRKP and it emphasizes the importance of using standard methods for infection control.

Overall bioburden by total colony count does not predict the presence of pathogens with high clinical relevance in hospital and community environments

BACKGROUND

Healthcare-associated infections (HAIs) affect millions of patients, increasing morbidity and mortality. Pathogens of HAIs originate from both the patient's own flora and the environment, including multi-drug-resistant organisms.

AIMS

To determine the bioburden on different types of high-touch surfaces, and to identify cultures to species level and stratify strains into those of low and high clinical relevance.

DESIGN

Association between bioburden and presence of pathogens of high clinical relevance (PHCR) in a tertiary care centre and urban environment.

METHODS

The overall bioburden measured by total colony count (TCC) was assessed using tryptic soy agar contact plates and two selective agars to improve detection of PHCR. Isolates were routinely identified to species level using matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF). The definition of PHCR was based on listings outlined by the Centers for Disease Control and Prevention.

FINDINGS

In total, 1431 contact plates were processed from 477 surfaces: 153 from hospitals and 324 from publicly accessible institutions or devices. At least one PHCR was identified from cultures from 73 samples. TCC was found to be poorly correlated with the presence of PHCR.

CONCLUSION

TCC poorly predicted the presence of PHCR, rendering the results from environmental sampling difficult to interpret. MALDI-TOF enables the identification of large numbers of isolates from the environment at low cost. Further studies on environmental contamination should use MALDI-TOF to identify all pathogens grown.

Faecal microbiota transplantation shortens the colonisation period and allows re-entry of patients carrying carbapenamase-producing bacteria into medical care facilities

BACKGROUND

Colonisation with carbapenemase-producing Enterobacteriaceae or Acinetobacter (CPE/A) is associated with complex medical care requiring implementation of specific isolation policies and limitation of patient discharge to other medical facilities. Faecal microbiota transplantation (FMT) has been proposed in order to reduce the duration of gut colonisation.

OBJECTIVES

This study investigated whether a dedicated protocol of FMT could reduce the negativation time of CPE/A intestinal carriage in patients whose medical care has been delayed due to such colonisation.

METHOD

A matched case-control retrospective study between patients who received FMT treatment and those who did not among CPE/A-colonised patients addressed for initial clustering at the current institute. The study adjusted two controls per case based on sex, age, bacterial species, and carbapenemase type. The primary outcome was delay in negativation of rectal-swab cultures.

RESULTS

At day 14 post FMT, 8/10 (80%) treated patients were cleared for intestinal CPE/A carriage. In the control group, 2/20 (10%) had spontaneous clearance at day 14 after CPE/A diagnosis. Faecal microbiota transplantation led patients to reduce the delay in decolonisation (median 3 days post FMT for treated patients vs. 50.5 days after the first documentation of digestive carriage for control patients) and discharge from hospital (median 19.5 days post FMT for treated patients vs. 41 for control patients).

CONCLUSION

Faecal microbiota transplantation is a safe and time-saving procedure to discharge CPE/A-colonised patients from the hospital. A standardised protocol, including 5 days of antibiotic treatment, bowel cleansing and systematic indwelling devices removal, should improve protocol effectiveness.

Comparison of nylon-flocked swab and cellulose sponge methods for carbapenem-resistant Enterobacteriaceae and gram-negative organism recovery from high-touch surfaces in patient rooms

The ideal sampling method and benefit of qualitative versus quantitative culture for carbapenem-resistant Enterobacteriaceae (CRE) recovery in hospitalized patient rooms and bathrooms is unknown. Although the use of nylon-flocked swabs improved overall gram-negative organism recovery compared with cellulose sponges, they were similar for CRE recovery. Quantitative culture was inferior and unrevealing beyond the qualitative results.

Carbapenem resistance among clinical and environmental Gram-negative isolates recovered from hospitals in Gaza strip, Palestine

Background

The world is threatened by the ongoing emergence of carbapenem resistant organisms, which are contributing to increasing morbidity and mortality rates. The main objective of this study was to highlight carbapenem resistance among clinical and environmental Gram-negative bacteria (GNB) isolates.

Methods

A cross-sectional study wherein 210 clinical isolates, 150 environmental swabs, and 110 air samples were collected from three major hospitals in Gaza strip: Al-Shifa, AlNaser and the European Gaza hospitals. The study lasted for seven months (September 2016 to March 2017). All isolates/samples were cultured and identified using conventional bacteriological methods. All GNB isolates were tested for their antimicrobial susceptibility using the disk diffusion method. Modified Hodge Test (MHT) was performed to investigate carbapenemases production.

Results

The overall percentage of carbapenem resistance among GNB was (30/247) 12.1%. Resistance to imipenem was (20/247) 8.1% while resistance to ertapenem and meropenem was (8/226) 3.5% and (2/247) 0.8%, respectively. The intensive care units exhibited the highest resistance rate 9/17 (52.9%). Carbapenem resistance among Enterobacteriaceae was (30/226) 13.2% while in Pseudomonas it was (0/21) 0%. Klebsiella spp. was the most resistant to carbapenems 13/90 (14.4%), followed by E. coli (9/91) 9.8%. Seven isolates out of 30 (23.3%) were positive for MHT. All Enterobacteriaceae isolates had a multiple antibiotic resistance (MAR) index higher than 0.2, while those of Pseudomonas had an average of 0.2. GNB were isolated from 19/110 (17.2%) and 21/150 (14%) of air and environmental samples, respectively.

Conclusion

The resistance found, after a recent introduction of carbapenem use in Gaza, shows the need for policies to prevent misuse and overuse of carbapenems, the need for infection control procedures and screening policies for carbapenem resistance on a routine basis.

A systematic review: the current status of carbapenem resistance in East Africa

OBJECTIVE

In this systematic review, we present the molecular epidemiology and knowledge gaps of the carbapenem resistance in East Africa as well as the future probable research interventions that can be used to address the emergence of carbapenem resistance in the region.

RESULTS

The 17 articles which presented concrete information about the prevalence of carbapenem resistance in East Africa were reviewed. Tanzania exhibited the highest level of carbapenem resistance at 35% while DRC had the lowest level at 0.96%. Uganda was the only country with studies documenting CR obtained amongst hospital environment isolates with incidence ranging from 21% in Pseudomonas aeruginosa to 55% in Acinetobacter baumannii. Carbapenem resistance was more exhibited in A. baumannii (23%), followed by P. aeruginosa (17%), Klebsiella pneumoniae (15%), Proteus mirabilis (14%) and Escherichia coli (12%) mainly isolated from respiratory tract, blood, urine and wound/pus. The regional genetic determinants of carbapenem resistance detected were blaIMP, blaVIM-1 blaSPM-l, blaNDM-1, blaOXA-23 blaOXA-24, blaOXA-58 and blaKPC.

Entérobactéries productrices de carbapénémases en médecine intensive : comment maîtriser le risque ?

La diffusion globale des entérobactéries productrices de carbapénémases principalement au niveau de certaines zones géographiques, dont le pourtour méditerranéen, est une situation préoccupante. Elle doit nous inciter à maintenir notre niveau de vigilance. Trois principaux mécanismes de résistance s’exprimant à des degrés variables sont décrits. Plusieurs critères tels que l’identification de la population à risque, la qualité du diagnostic microbiologique, la gestion du risque ainsi que la diffusion intrahospitalière doivent être maîtrisés. Une politique d’amélioration de l’hygiène des mains, le respect des précautions complémentaires d’hygiène ainsi que la maîtrise de la consommation des antibiotiques sont plus que nécessaires.

Distribution, genetic diversity and antimicrobial resistance of clinically important bacteria from the environment of a tertiary hospital in Malaysia

OBJECTIVES

Hospital environments are potential reservoirs of bacteria associated with nosocomial infections. In this study, the distribution of cultivable environmental bacteria of clinical importance from a Malaysian tertiary hospital was determined and their resistotypes and genotypes were investigated.

METHODS

Swab and fluid samples (n=358) from healthcare workers' hands, frequently touched surfaces, medical equipment, patients' immediate surroundings, ward sinks and toilets, and solutions or fluids of 12 selected wards were collected. Biochemical tests, PCR and 16S rRNA sequencing were used for identification following isolation from CHROMagar™ Orientation medium. Clinically important bacteria such as Enterococcus spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter spp., Pseudomonas aeruginosa and Enterobacter spp. were further characterised by disc diffusion method and rep-PCR.

RESULTS

The 24 Gram-negative and 19 Gram-positive bacteria species identified were widely distributed in the hospital environment. Staphylococci were predominant, followed by Bacillus spp. and P. aeruginosa. Frequently touched surfaces, medical equipment, and ward sinks and toilets were the top three sources of bacterial species. Nine S. aureus, four Acinetobacter spp., one K. pneumoniae and one Enterobacter spp. were multidrug-resistant (MDR). The ESKAPE organisms were genetically diverse and widely dispersed across the hospital wards. A MDR MRSA clone was detected in a surgical ward isolation room.

CONCLUSION

The large variety of cultivable, clinically important bacteria, especially the genetically related MDR S. aureus, K. pneumoniae, Acinetobacter spp. and Enterobacter spp., from various sampling sites indicated that the surfaces and fomites in the hospital were potential exogenous sources of nosocomial infection in the hospital.

'No touch' technologies for environmental decontamination: focus on ultraviolet devices and hydrogen peroxide systems

PURPOSE OF REVIEW

This article reviews 'no touch' methods for disinfection of the contaminated surface environment of hospitalized patients' rooms. The focus is on studies that assessed the effectiveness of ultraviolet (UV) light devices, hydrogen peroxide systems, and self-disinfecting surfaces to reduce healthcare-associated infections (HAIs).

RECENT FINDINGS

The contaminated surface environment in hospitals plays an important role in the transmission of several key nosocomial pathogens including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., Clostridium difficile, Acinetobacter spp., and norovirus. Multiple clinical trials have now demonstrated the effectiveness of UV light devices and hydrogen peroxide systems to reduce HAIs. A limited number of studies have suggested that 'self-disinfecting' surfaces may also decrease HAIs.

SUMMARY

Many studies have demonstrated that terminal cleaning and disinfection with germicides is often inadequate and leaves environmental surfaces contaminated with important nosocomial pathogens. 'No touch' methods of room decontamination (i.e., UV devices and hydrogen peroxide systems) have been demonstrated to reduce key nosocomial pathogens on inoculated test surfaces and on environmental surfaces in actual patient rooms. Further UV devices and hydrogen peroxide systems have been demonstrated to reduce HAI. A validated 'no touch' device or system should be used for terminal room disinfection following discharge of patients on contact precautions. The use of a 'self-disinfecting' surface to reduce HAI has not been convincingly demonstrated.

VIM-Klebsiella oxytoca outbreak in a Neonatal Intensive Care Unit. This time it wasn't the drain

Objective

We describe an outbreak of VIM-carbapenemase Klebsiella oxytoca (VIM-Kox) in a NICU

Materials and methods

Prospective Epidemiological Surveillance:

Molecular typing was performed using the DiversiLab (bioMérieux) system on all VIM-Kox isolated from environment or patients (one by neonate).

Results

We identified 20 VIM-Kox cases, the most only presented colonization, but 4 showed infection. Three of the ten sinks (drains) in our NICU, were positive for VIM-Kox. Another four drains harbored P.aeruginosa, S. maltophilia and/or Enterobacter sp. Nevertheless the VIM-Kox bacteria in the sinks (drains) were not the same as those in the patients, who showed three different strains.

Conclusions

A VIM-Kox colonization or infection outbreak in a NICU is described. Rather than environment, not even drains, the source of the outbreak was other patients. The outbreak was relatively brief, as a result of the rapidness with which appropriate measures were taken and followed.