Infections caused by extended-spectrum beta-lactamases producing Enterobacteriaceae: clinical and economic impact in patients hospitalized in 2 teaching hospitals in Dakar, Senegal

Direct economic costs related to antimicrobial resistance in bloodstream infections isolated from newborns in a perinatal hospital in Peru

BACKGROUND

Antimicrobial resistance (AMR) has emerged as a priority for both public health and the global economy. Moreover, information on AMR is scarce, particularly in low/middle-income countries. We evaluated the direct economic cost of microorganisms and AMR.

METHODS

We performed a cross-sectional study to assess the economic costs of neonatal cases diagnosed with bacteremia at the Instituto Nacional Materno Perinatal in Lima, Peru, from January 2017 to June 2018. We used cost invoices calculated by the micro-costing bottom-up approach, as well as the strain identification and antimicrobial susceptibility data, to estimate the direct costs.

RESULTS

The average costs of bacteremia were US$349 (SD 403) for multidrug-resistant (MDR) strains and US$276 (SD 349) for non-MDR strains. Costs were higher for microorganisms associated with late-onset sepsis (LOS). We found that LOS, multidrug resistance and age were significantly associated with bloodstream infection (BSI) costs. Also, all microorganism groups were associated with increased costs, with the highest average costs for Acinetobacter, followed by Pseudomonas.

CONCLUSIONS

In Peru, BSI costs are strongly associated with AMR. Furthermore, costs increase significantly with LOS, multidrug resistance and the patient's age. We urge health authorities to strengthen measures and strategies against the pressing threat of AMR.

Disease burden of bacteraemia with extended-spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in Korea

BACKGROUND

Despite the significant impact of multi-drug-resistant bacteraemia, especially extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) and carbapenem-resistant Enterobacterales (CRE), the burden of disease has not been investigated thoroughly.

AIM

To evaluate the clinical outcomes and socio-economic burden of ESBL-E and CRE bacteraemia nationwide in the Republic of Korea.

METHODS

A search was undertaken for all cases of ESBL-E and CRE bacteraemia and matched controls in 10 hospitals in the Republic of Korea over 6 months. Patients with ESBL-E or CRE bacteraemia were classified as the R group, and matched controls with antibiotic-susceptible bacteraemia and without infection were classified as the S and N groups, respectively. Patients' clinical data were collected, and the economic burden was estimated based on medical expenses, loss of productivity and total costs.

FINDINGS

In total, 795 patients were identified, including 265 patients with ESBL-E or CRE bacteraemia and their matched controls. The mean total length of stay for patients with ESBL-E and CRE in the R group was 1.53 and 1.90 times that of patients in the S group, respectively. The 90-day mortality rates for ESBL-E in the R and S groups were 12.1% and 5.6%, respectively, and the corresponding figures for CRE were 28.6% and 12.0%. There were significant differences in the total costs between the R, S and N groups for both ESBL-E and CRE (ESBL-E: $11,151 vs $8712 vs $6063, P=0.004; CRE: $40,464 vs $8748 vs $7279, P=0.024).

CONCLUSION

The clinical and economic burden imposed by ESBL-E or CRE bacteraemia was extremely high. These findings suggest that efforts to control resistant bacteraemia are necessary to reduce this burden.

Antimicrobial Susceptibility and Characterization of Extended-Spectrum β-Lactamase-Producing Escherichia coli Isolated from Stools of Primary Healthcare Patients in Ethiopia

Antimicrobial resistance of Escherichia coli is a growing problem in both developed and developing countries. This study aimed to investigate the phenotypic antimicrobial resistance of E. coli isolates (n = 260) isolated from the stool specimen of patients attending public health facilities in Addis Ababa and Hossana. This study also aimed to characterize phenotypically confirmed extended-spectrum beta-lactamase (ESBL)-producing E. coli isolates (n = 22) using whole-genome sequencing. Resistance to 18 different antimicrobials was assessed using the disc diffusion method according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. The highest resistance rate among the E. coli isolates was found for ampicillin (52.7%), followed by trimethoprim-sulfamethoxazole (29.6%). Of all isolates, 50 (19.2%) were multidrug-resistant and 22 (8.5%) were ESBL producers. ESBL genes were detected in 94.7% of the sequenced E. coli isolates, and multiple β-lactamase genes were detected in 57.9% of the isolates. The predominant ESBL gene identified was blaCTX-M-15 (78.9%). The blaTEM-1B gene was detected in combination with other ESBL genes in 57.9% of the isolates, while only one of the sequenced isolates contained the blaTEM-1B gene alone. The blaCTX-M-3 gene was detected in three isolates. The genes blaCTX-M-15 and blaTEM-1B as well as blaCTX-M-15 and blaTEM-169 were confirmed to coexist in 52.6% and 10.5% of the sequenced E. coli isolates, respectively. In addition, blaOXA-1 was identified together with blaCTX-M-15 and blaTEM-1B in one isolate, and in one isolate, blaTEM-169 together with blaCTX-M-15 and blaTEM-1B was found. The results obtained show that measures need to be taken to reduce the spread of drug resistance and ensure the long-term use of available antimicrobials.

Mortality associated with third-generation cephalosporin resistance in Enterobacterales bloodstream infections at eight sub-Saharan African hospitals (MBIRA): a prospective cohort study

BACKGROUND

Bacteria of the order Enterobacterales are common pathogens causing bloodstream infections in sub-Saharan Africa and are frequently resistant to third-generation cephalosporin antibiotics. Although third-generation cephalosporin resistance is believed to lead to adverse outcomes, this relationship is difficult to quantify and has rarely been studied in this region. We aimed to measure the effects associated with resistance to third-generation cephalosporins in hospitalised patients with Enterobacterales bloodstream infection in Africa.

METHODS

We conducted a prospective, matched, parallel cohort study at eight hospitals across sub-Saharan Africa. We recruited consecutive patients of all age groups with laboratory-confirmed Enterobacterales bloodstream infection and matched them to at least one patient without bloodstream infection on the basis of age group, hospital ward, and admission date. Date of infection onset (and enrolment) was defined as the day of blood sample collection for culturing. Patients infected with bacteria with a cefotaxime minimum inhibitory concentration of 1 mg/L or lower were included in the third-generation cephalosporin-susceptible (3GC-S) cohort, and the remainder were included in the third-generation cephalosporin-resistant (3GC-R) cohort. The primary outcomes were in-hospital death and death within 30 days of enrolment. We used adjusted multivariable regression models to first compare patients with bloodstream infection against matched patients within the 3GC-S and 3GC-R cohorts, then compared estimates between cohorts.

FINDINGS

Between Nov 1, 2020, and Jan 31, 2022, we recruited 878 patients with Enterobacterales bloodstream infection (221 [25·2%] to the 3GC-S cohort and 657 [74·8%] to the 3GC-R cohort) and 1634 matched patients (420 [25·7%] and 1214 [74·3%], respectively). 502 (57·2%) bloodstream infections occurred in neonates and infants (age 0-364 days). Klebsiella pneumoniae (393 [44·8%] infections) and Escherichia coli (224 [25·5%] infections) were the most common Enterobacterales species identified. The proportion of patients who died in hospital was higher in patients with bloodstream infection than in matched controls in the 3GC-S cohort (62 [28·1%] of 221 vs 22 [5·2%] of 420; cause-specific hazard ratio 6·79 [95% CI 4·06-11·37] from Cox model) and the 3GC-R cohort (244 [37·1%] of 657 vs 115 [9·5%] of 1214; 5·01 [3·96-6·32]). The ratio of these cause-specific hazard ratios showed no significant difference in risk of in-hospital death in the 3GC-R cohort versus the 3GC-S cohort (0·74 [0·42-1·30]). The ratio of relative risk of death within 30 days (0·82 [95% CI 0·53-1·27]) also indicated no difference between the cohorts.

INTERPRETATION

Patients with bloodstream infections with Enterobacterales bacteria either resistant or susceptible to third-generation cephalosporins had increased mortality compared with uninfected matched patients, with no differential effect related to third-generation cephalosporin-resistance status. However, this finding does not account for time to appropriate antibiotic treatment, which remains clinically important to optimise. Measures to prevent transmission of Enterobacterales could reduce bloodstream infection-associated mortality from both drug-resistant and drug-susceptible bacterial strains in Africa.

FUNDING

Bill & Melinda Gates Foundation.

High frequency and molecular characterization of ESBL-producing Enterobacteriaceae isolated from wound infections in North Lebanon

BACKGROUND

Extended-spectrum beta-lactamases producing Enterobacteriaceae (ESBL-PE) represent a major problem in wound infections. Here, we investigated the prevalence and molecular characterization of ESBL-PE associated with wound infections in North Lebanon.

RESEARCH DESIGN AND METHODS

A total of 103 non-duplicated E. coli and K. pneumoniae strains isolated from 103 patients with wound infections, were collected from seven hospitals in North Lebanon. ESBL-producing isolates were detected using a double-disk synergy test. In addition, multiplex polymerase chain reaction (PCR) was used for the molecular detection of ESBLs genes.

RESULTS

E. coli was the predominant bacteria (77.6%), followed by K. pneumoniae (22.3%). The overall prevalence of ESBL-PE was 49%, with a significantly higher rate among females and elderly patients. K. pneumoniae was the common MDR and ESBL-producer bacteria (86.95% and 52.17%) compared to E. coli (77.5% and 47.5%). Most of the isolated ESBL producers harbored multiple resistant genes (88%), where blaCTX-M was the most predominant gene (92%), followed by blaTEM (86%), blaSHV (64%), and blaOXA genes (28%).

CONCLUSIONS

This is the first data on the ESBL-PE prevalence associated with wound infections in Lebanon, showing the emergence of multidrug-resistant ESBL-PE, the dominance of multiple gene producers, and the widespread dissemination of blaCTX-M and blaTEM genes.

Individual and population level costs and health-related quality of life outcomes of third-generation cephalosporin resistant bloodstream infection in Blantyre, Malawi

Data which accurately enumerate the economic costs of antimicrobial resistance (AMR) in low- and middle- income countries are essential. This study aimed to quantify the impact of third-generation cephalosporin resistant (3GC-R) bloodstream infection (BSI) on economic and health related quality of life outcomes for adult patients in Blantyre, Malawi. Participants were recruited from a prospective, longitudinal cohort study of hospitalised patients with bloodstream infection caused by Enterobacterales at Queen Elizabeth Central Hospital (QECH). Primary costing studies were used to estimate the direct medical costs associated with the inpatient stay. Recruited participants were asked about direct non-medical and indirect costs associated with their admission and their health-related quality of life was measured using the EuroQol EQ-5D questionnaire. Multiple imputation was undertaken to account for missing data. Costs were adjusted to 2019 US Dollars. Cost and microbiology surveillance data from QECH, Blantyre was used to model the annual cost of, and quality-adjusted life years lost to, 3GC-R and 3GC-Susceptible BSI from 1998 to 2030 in Malawi. The mean health provider cost per participant with 3GC-R BSI was US$110.27 (95%CR; 22.60-197.95), higher than for those with 3GC-S infection. Patients with resistant BSI incurred an additional indirect cost of US$155.48 (95%CR; -67.80, 378.78) and an additional direct non-medical cost of US$20.98 (95%CR; -36.47, 78.42). Health related quality of life outcomes were poor for all participants, but participants with resistant infections had an EQ-5D utility score that was 0.167 (95% CR: -0.035, 0.300) lower than those with sensitive infections. Population level burden estimates suggest that in 2016, 3GC-R accounted for 84% of annual societal costs from admission with bloodstream infection and 82% of QALYs lost. 3GC-R bloodstream infection was associated with higher health provider and patient level costs than 3GC-S infection, as well as poorer HRQoL outcomes. We demonstrate a substantial current and future economic burden to society as a result of 3GC-R E. coli and Klebsiella spp. BSI, data urgently needed by policy makers to provide impetus for implementing strategies to reduce AMR.

Molecular Epidemiology of Escherichia coli with Resistance against Third-Generation Cephalosporines Isolated from Deployed German Soldiers-A Retrospective Assessment after Deployments to the African Sahel Region and Other Sites between 2007 and 2016

Colonization and infection with bacteria with acquired antibiotic resistance are among the risks for soldiers on international deployments. Enterobacterales with resistance against third-generation cephalosporines are amongst the most frequently imported microorganisms. To contribute to the scarcely available epidemiological knowledge on deployment-associated resistance migration, we assessed the molecular epidemiology of third-generation cephalosporine-resistant Escherichia coli isolated between 2007 and 2016 from German soldiers after deployments, with a particular focus on the African Sahel region. A total of 51 third-generation cephalosporine-resistant E. coli isolated from 51 military returnees from deployment collected during the assessment period between 2007 and 2016 were subjected to short-read next-generation sequencing analysis. Returnees from the Sahel region (Djibouti, Mali, South Sudan, Sudan, Sudan, and Uganda) comprised a proportion of 52.9% (27/51). Repeatedly isolated sequence types according to the Warwick University scheme from returnees from the Sahel region were ST38, ST131, and ST648, confirming previous epidemiological assessments from various sub-Saharan African regions. Locally prevalent resistance genes in isolates from returnees from the Sahel region associated with third-generation resistance were bla_CTX-M-15, bla_CTX-M-27, bla_CTX-M-1, bla_TEM-169, bla_CTX-M-14, bla_CTX-M-99-like, bla_CTX-M-125, bla_SHV-12, and bla_DHA-1, while virulence genes were east1, sat, and tsh in declining order of frequency of occurrence each. In line with phenotypically observed high resistance rates for aminoglycosides and trimethoprim/sulfamethoxazole, multiple associated resistance genes were observed. A similar, slightly more diverse situation was recorded for the other deployment sites. In summary, this assessment provides first next-generation sequencing-based epidemiological data on third-generation cephalosporine-resistant E. coli imported by deployed German soldiers with a particular focus on deployments to the Sahel region, thus serving as a small sentinel. The detected sequence types are well in line with the results from previous epidemiological assessments in sub-Saharan Africa.

Molecular Epidemiological Characterisation of ESBL- and Plasmid-Mediated AmpC-Producing Escherichia coli and Klebsiella pneumoniae at Kamuzu Central Hospital, Lilongwe, Malawi

The global rise in infections caused by multidrug resistant (MDR) Enterobacterales poses a public health problem. We have performed a molecular epidemiological characterisation of representative plasmid-mediated AmpC (pAmpC) and ESBL-positive clinical isolates of Escherichia coli (n = 38) and Klebsiella pneumoniae (n = 17) from a tertiary hospital in Malawi collected in 2017. BlaCTX-M-15 was the most prevalent ESBL-determinant in E. coli (n = 30/38) and K. pneumoniae (n = 17/17), whereas blaCMY-2 was detected in nearly all AmpC-phenotype E. coli (n = 15/17). Whole genome sequencing revealed dominant globally disseminated E. coli sequence types (STs); ST410 (n = 16), ST131 (n = 7), and ST617 (n = 6). The ST distribution in K. pneumoniae was more diverse but included ST101 (n = 2), ST14 (n = 2), and ST340 (n = 2), all considered high-risk MDR clones. The isolates expressed an MDR profile, including resistance against commonly used antibiotics, such as fluoroquinolones, aminoglycosides, and/or trimethoprim-sulfamethoxazole, and harboured corresponding resistance determinants. Clonal analyses of the major STs of E. coli revealed closely related genetic clusters within ST410, ST131, and ST617 supporting within-hospital transmission between patients and/or via a common reservoir. The overall findings add to the limited knowledge on the molecular epidemiology of MDR E. coli and K. pneumoniae in Malawi and may help health policy makers to identify areas to target when addressing this major threat of antibiotic resistance.

Attributable mortality and excess length of stay associated with third-generation cephalosporin-resistant Enterobacterales bloodstream infections: a prospective cohort study in Suva, Fiji

OBJECTIVES

There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the effect of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji.

METHODS

We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and we used multistate modelling to estimate the excess length of hospital stay.

RESULTS

From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs; 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio [aHR] 1.13, 95% confidence interval [CI] 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission.

CONCLUSION

Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.

Mortality associated with third-generation cephalosporin resistance in Enterobacteriaceae bloodstream infections at one South African hospital

OBJECTIVES

Enterobacteriaceae are common pathogens causing bloodstream infection (BSI) in sub-Saharan Africa and frequently express third-generation cephalosporin (3GC) resistance; however, the impact of 3GC resistance on clinical outcomes is rarely studied.

METHODS

We conducted a single-site prospective cohort study at Tygerberg Hospital, Cape Town, South Africa to examine the feasibility of measuring impacts of 3GC resistance in Enterobacteriaceae BSI. We included patients with 3GC-susceptible and 3GC-resistant BSIs and matched each BSI patient to two uninfected patients. We determined the concordance of initial antibiotic treatment with the corresponding isolate's susceptibility profile. We performed exploratory impact analysis using multivariable regression models.

RESULTS

Between 1 June 2017 and 31 January 2018, we matched 177 Enterobacteriaceae BSI patients to 347 uninfected patients. Among these BSIs, 35% were phenotypically 3GC resistant. Parameters describing clinical comorbidity showed strong associations with mortality. We found that 18% of 3GC-R and 3% of 3GC-S BSI patient received non-concordant initial therapy. In multivariable Cox regression, we found a mortality impact over their matched patients for both 3GC-R (cause-specific hazard ratio 23.77; 95% CI 5.12-110.3) and 3GC-S (HR 7.49; 95%CI 3.08-18.19) BSI. There was a nonsignificant ratio of these ratios (HR 3.18; 95% CI 0.54-18.70), limited by the small sample size.

CONCLUSION

This form of impact estimation was feasible in one hospital in South Africa where 3GC-R status was associated with non-concordant initial antibiotic treatment. There was a possible increase in mortality among individuals with 3GC-resistant Enterobacteriaceae, but with broad confidence intervals. These analytical approaches could be applied to larger datasets to improve precision of estimates.

The Effect of Infection Precautions on Extended-Spectrum Beta-Lactamase Enterobacteriaceae Colonization Among Nurses in Three Beirut Hospitals

Background and objective

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) are rapidly emerging worldwide. This study aimed to assess the effect of contact precaution (CP) on ESBL-PE-colonization rates among nurses in three hospitals in Beirut, Lebanon, where ESBL is endemic, in order to define the risk factors for colonization. Accordingly, the ongoing use of CP to prevent ESBL-PE transmission to healthy nurses was evaluated.

Methods

This cross-sectional study was conducted in three hospitals. Hospital 1 required CP, Hospital 2 had recently stopped CP, and Hospital 3 had stopped it three years previously. Questionnaires and stool-collection containers were distributed to all patient care nurses in those three hospitals. The Returned samples were tested using the agar dilution technique.

Results

A total of 269 out of 733 nurses volunteered to participate; 140 met the inclusion criteria (no recent hospitalization, antibiotic use, or known ESBL-PE colonization) and provided samples. Among them, 15% were ESBL-positive. Compared to nurses from Hospital 3, nurses from Hospital 1 were 59% less likely to be colonized, while nurses from Hospital 2 were 62% more likely to be colonized.

Conclusion

In hospitals where CP is in place for ESBL-positive patients, ESBL-PE prevalence in nursing staff was significantly lower. Additionally, a work experience of two to four years increased the odds of ESBL-PE colonization in comparison with longer nursing experience. CP may be a justifiable means of protection against ESBL-PE transmission to healthy nurses. The risk factors for colonization were discontinuation of CP and a shorter clinical work experience.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

2003-2019: explosive spread of enterobacteria producing extended-spectrum beta-lactamases in Bangui Central African Republic

Introduction

the spread of enterobacteria producing extended-broad-spectrum beta-lactamases (ESBL) is a global public health-problem. In a study carried in 2003-2005 at the Pasteur Institute in Bangui, 450 enterobacteria were identified in clinical isolates, of which 17 were ESBL (prevalence: 3.78%). The aim of this study was to update this data.

Methods

from May 2018 to April 2019, a total of 941 enterobacteria were isolated and identified under identical conditions of recruitment and with the same techniques used in the previous study: phenotypic identification using Api 20E strips (bioMérieux SA, Marcy-l'Etoile, France) and antimicrobial drug susceptibility using the disk diffusion method (Bio-Rad antibiotic discs, Marnes la Coquette, France). Resistance genes were identified by polymerase chain reaction (PCR) and sequencing.

Results

from May 2018 to April 2019, a total of 941 enterobacteria were isolated of which 478 were ESBL, thus amounting to a prevalence of 50.80%. The genetic profiles of the bla CTX-M resistance genes exhibited the emergence of the CTX-M28 variant (CTX-M1 group) and variants of the M2 and M9 groups. There was also a notable increase, from 35 to 64%, in the ESBL with a bla SHV gene.

Conclusion

this study documents a 13 fold increase in the prevalence of ESBL derived from clinical isolates of the bacteriology laboratory of the Institute Pasteur in Bangui, by comparing its data with that of the publication by Frank et al. 2006. Together with this increase a significant diversification of the circulating CTX-M resistance genes was noticed.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study

OBJECTIVES

The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective.

METHODS

A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality.

RESULTS

Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality.

CONCLUSION

In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Feasibility and potential significance of rapid in vitro qualitative phenotypic antimicrobial susceptibility testing of gram-negative bacilli with the ProMax system

The emergence and evolution of antibiotic resistance has been accelerated due to the widespread use of antibiotics and a lack of timely diagnostic tests that guide therapeutic treatment with adequate sensitivity, specificity, and antimicrobial susceptibility testing (AST) accuracy. Automated AST instruments are extensively used in clinical microbiology labs and provide a streamlined workflow, simplifying susceptibility testing for pathogenic bacteria isolated from clinical samples. Although currently used commercial systems such as the Vitek2 and BD Phoenix can deliver results in substantially less time than conventional methods, their dependence on traditional AST inoculum concentrations and optical detection limit their speed somewhat. Herein, we describe the GeneFluidics ProMax lab automation system intended for a rapid 3.5-hour molecular AST from clinical isolates. The detection method described utilizes a higher starting inoculum concentration and automated molecular quantification of species-specific 16S rRNA through the use of an electrochemical sensor to assess microbiological responses to antibiotic exposure. A panel of clinical isolates consisting of species of gram-negative rods from the CDC AR bank and two hospitals, New York-Presbyterian Queens and Medical College of Wisconsin, were evaluated against ciprofloxacin, gentamicin, and meropenem in a series of reproducibility and clinical studies. The categorical agreement and reproducibility for Citrobacter freundii, Enterobacter cloacae, Escherichia coli, Klebsiella aerogenes, Klebsiella oxytoca, Klebsiella pneumoniae, and Pseudomonas aeruginosa were 100% and 100% for ciprofloxacin, 98.7% and 100% for gentamicin and 98.5% and 98.5% for meropenem, respectively.

Gram Negative Extended Spectrum Beta-Lactamase Producing Bacteria Prevalence in Jouf Region Tertiary Care Hospital, Saudi Arabia

Extended Spectrum beta lactamase producing pathogens are reported in many clinical samples and pose an emerging threat health. To find the prevalence of ESBL producing Enterobactriacea pathogens isolated from inpatients (Medical and Surgical Wards; Hospital stay > 72 h) admitted to Prince, Mutib, Hospital Sakaka, Jouf. A total of 1043 Enterobactriacea were isolated during April 2015 to October 2016 study period. Vitek -2 compact (biomeriux Leon, France) was used for identification and antimicrobial sensitivity (AST) test. A Total of 115/1043 (11.02%) ESBL producing pathogens were isolated from urine 15.07% (n=242), sputum 13.6 % (n=220), wound 10.8% (n=287) and blood 5.4 % (n=294). Klebsiella pneumonia is most dominant followed by E coli and Proteus miribilis. Cephamycins and carbapenems were found most effective (100% sensitivity) against the pathogens isolated. The aminoglycosides, beta lactams and Fluroquinolnes class of antibiotics, microorganisms have gained the resistance of 20%, 22.7%, 40-70% respectively. The infection control measures should be taken seriously and making of effective use of antibiotics is need of hour.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study

OBJECTIVES

The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective.

METHODS

A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality.

RESULTS

Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality.

CONCLUSION

In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Mortality attributable to third-generation cephalosporin resistance in Gram-negative bloodstream infections in African hospitals: a multi-site retrospective study

Background

Bloodstream infections (BSI) caused by Enterobacteriaceae show increasing frequency of resistance to third-generation cephalosporin (3GC) antibiotics on the African continent but the mortality impact has not been quantified.

Methods

We used historic data from six African hospitals to assess the impact of 3GC resistance on clinical outcomes in Escherichia coli and Klebsiella pneumoniae BSI. We matched each bacteraemic patient to two uninfected patients. We compared outcomes between 3GC-susceptible and 3GC-resistant BSI and their respective uninfected controls using Cox regression models.

Results

For 1431 E. coli BSI patients, we matched 1152 (81%) 3GC-susceptible and 279 (19%) 3GC-resistant cases to 2263 and 546 uninfected inpatient controls. For 1368 K. pneumoniae BSI patients, we matched 502 (37%) 3GC-susceptible and 866 (63%) 3GC-resistant cases to 982 and 1656 uninfected inpatient controls. We found that 3GC-resistant E. coli had similar hazard ratios (HRs) for in-hospital mortality over their matched controls as compared to susceptible infections over their controls (ratio of HRs 1.03, 95% CI 0.73–1.46). Similarly, 3GC-resistance in K. pneumoniae BSI was not associated with mortality (ratio of HR 1.10, 95% CI 0.80–1.52). Estimates of mortality impact varied by site without a consistent pattern.

Conclusions

In a retrospective analysis, including the use of matched uninfected patients, there did not appear to be an impact of 3GC-resistance on mortality in E. coli or K. pneumoniae BSI in African hospitals, as compared with susceptible BSI with equivalent species. Better information on the actual use of antibiotics in treating infections in African hospitals would improve these impact estimates.

Clinical outcomes and prognostic factors in bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae among patients with malignancy: a meta-analysis

Background

The colonization of Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) in bloodstream infections (BSIs) has been increased dramatically worldwide, and it was associated with worse clinical outcomes in patients with malignancy. We performed the meta-analysis to investigate the prognosis and risk factors in BSIs caused by ESBL-PE in oncological patients.

Methods

PubMed, EMBASE, and Cochrane Library were searched for related studies. All-cause mortality was considered as the primary outcome. Subgroup analyses, meta-regression analyses, and sensitivity analysis were used to investigate heterogeneity and reliability in results.

Results

6,729 patients from 25 studies were eligible. Six studies enrolled oncological patients with BSIs caused by ESBL-PE only, while 19 studies both enrolled ESBL-PE and non-ESBL-PE infections. The results showed that BSIs caused by ESBL-PE in patients with malignancy was associated with higher mortality than non-ESBL-PE infections (RR = 2.21, 95% CI: 1.60–3.06, P < 0.001), with a significant between-study heterogeneity (I² =78.3%, P < 0.001). Subgroup analyses showed that children (RR = 2.80, 95% CI: 2.29–3.43, P < 0.001) and hematological malignancy (RR = 3.20, 95% CI: 2.54–4.03, P < 0.001) were associated with a higher mortality. Severe sepsis/ septic shock, pneumonia, and ICU admission were the most common predictors of mortality.

Conclusions

Our study identified that BSIs caused by ESBL-PE in patients with malignancy were associated with worse clinical outcomes compared with non-ESBL-PE infections. Furthermore, children and hematological malignancy were associated with higher mortality. Severe sepsis/ septic shock, pneumonia, and ICU admission were the most common predictors of mortality.

A systematic review on the prevalence of extended-spectrum beta lactamase-producing Gram-negative bacteria in Nigeria

OBJECTIVE

There are numerous reported cases of extended-spectrum beta-lactamases (ESBLs) producing Enterobacteriaceae in Nigeria. Yet, there are regions in Nigeria where cases of ESBL were under-reported. The review aims to assess the prevalence of ESBL-producing Gram-negative bacteria in Nigeria and the genes involved.

METHODS

An extensive literature search was carried out through an electronic database including PubMed, Scopus, Google Scholar and African Journals Online (AJOL). Articles published between January 2004 and November 2019 were included in the study. The titles and abstracts of the retrieved articles were reviewed, and then the full texts of the selected articles were reviewed. Articles were divided according to geopolitical zones.

RESULTS

Among the 217 articles identified, 60 studies (10 from north-central, 4 from northeast, 7 from the northwest, 17 from the southeast, 10 from south-south, and 12 from southwest Nigeria) were included. The highest prevalence recorded was 82.3%, while the lowest was 7.5%. The genes TEM, SHV, and CTX-M were the predominant variant commonly found. The most frequently used phenotypic detection method is the double disc synergy test (DDST).

CONCLUSION

ESBL-producing Gram-negative bacteria in hospital and community settings in Nigeria were commonly found. The prevalence of ESBL is very high, with one of the geopolitical zones under-reported. Future research should be conducted in these zones where there are scant studies, and a holistic approach involving the clinicians, researchers, laboratory scientists, and patients will go a long way in reducing the dissemination of this resistance mechanism.

The burden of extended-spectrum β-lactamase-producing Enterobacteriaceae in Nigeria: a systematic review and meta-analysis

Antibiotic resistance on account of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has become a major public health concern in developing countries. The presence of ESBL-PE is associated with increased morbidity, mortality and healthcare costs. There is no active antimicrobial surveillance mechanism in Nigeria. The aim of this study is to determine a precise estimate of the burden of ESBL-PE in Nigeria. We employed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched electronic databases for suitable studies. We derived pooled prevalence estimates using random effects models and assessed trends with meta-regression. We found 208 studies, with 38 satisfying our inclusion criteria. The overall pooled prevalence of ESBL-PE in Nigeria was 34.6% (95% CI 26.8 to 42.3%) and increased at a rate of 0.22% per year (p for trend=0.837). In summary, we found the prevalence of ESBL-PE in Nigeria to be high and recommend a robust national survey to provide a more detailed picture of the epidemiology of ESBL-PE in Nigeria.

Analysis of Resistance Gene Prevalence in Whole-Genome Sequenced Enterobacteriales from Brazil

Enterobacteriales is an order of bacteria responsible for community and hospital-acquired infections related to high rates of antimicrobial resistance and increased treatment costs, morbidity, and mortality globally. The aims of this study were to analyze the frequency of the resistance genes detected and distribution over the years and sources of isolation in sequenced Enterobacteriales strains isolated in Brazil and available at the Pathogen Detection website. The presence of resistance genes was analyzed in 1,507 whole-genome sequenced strains of 19 Enterobacteriales species. A total of 58.0% of the strains presented resistance genes to at least one antimicrobial class and 684 strains presented a multidrug-resistant (MDR) profile. Resistance genes to 14 classes of antimicrobials were detected. Aminoglycosides presented the most prevalent and diverse resistance genes, while the sulfonamide resistance gene, sul2, was the most prevalent among the strains studied. The presence of resistance genes from 14 different antimicrobial classes, the high levels of MDR strains, and the detection of genes related to clinical and veterinary-used drugs reinforce the necessity of more efficient control measures. Moreover, it warns for the necessity of the rational use of antimicrobials in veterinary and clinical situations in Brazil, since contaminated food may act as a vehicle for human infections.

Aetiology of invasive bacterial infection and antimicrobial resistance in neonates in sub-Saharan Africa: a systematic review and meta-analysis in line with the STROBE-NI reporting guidelines

BACKGROUND

Aetiological data for neonatal infections are essential to inform policies and programme strategies, but such data are scarce from sub-Saharan Africa. We therefore completed a systematic review and meta-analysis of available data from the African continent since 1980, with a focus on regional differences in aetiology and antimicrobial resistance (AMR) in the past decade (2008-18).

METHODS

We included data for microbiologically confirmed invasive bacterial infection including meningitis and AMR among neonates in sub-Saharan Africa and assessed the quality of scientific reporting according to Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI) checklist. We calculated pooled proportions for reported bacterial isolates and AMR.

FINDINGS

We included 151 studies comprising data from 84 534 neonates from 26 countries, almost all of which were hospital-based. Of the 82 studies published between 2008 and 2018, insufficient details were reported regarding most STROBE-NI items. Regarding culture positive bacteraemia or sepsis, Staphylococcus aureus, Klebsiella spp, and Escherichia coli accounted for 25% (95% CI 21-29), 21% (16-27), and 10% (8-10) respectively. For meningitis, the predominant identified causes were group B streptococcus 25% (16-33), Streptococcus pneumoniae 17% (9-6), and S aureus 12% (3-25). Resistance to WHO recommended β-lactams was reported in 614 (68%) of 904 cases and resistance to aminoglycosides in 317 (27%) of 1176 cases.

INTERPRETATION

Hospital-acquired neonatal infections and AMR are a major burden in Africa. More population-based neonatal infection studies and improved routine surveillance are needed to improve clinical care, plan health systems approaches, and address AMR. Future studies should be reported according to standardised reporting guidelines, such as STROBE-NI, to aid comparability and reduce research waste.

FUNDING

Uduak Okomo was supported by a Medical Research Council PhD Studentship.

Practice of over-the-counter dispensary of antibiotics for childhood illnesses in Addis Ababa, Ethiopia: a simulated patient encounter study

Background

Dispensary and use of antibiotics without prescriptions from qualified providers is a common practice in countries with poor pharmaceutical regulations and where due focus is not given to rational use. This practice is a main factor for the spread of antimicrobial resistance due to its non-reliance on pre-treatment microbiologic work-up, improper indications and dosing errors. This study was conducted to determine the rate of over-the-counter dispensary of antibiotics for common childhood illnesses among privately owned medicine retail outlets in Addis Ababa, Ethiopia.

Methods

Pre-determined simulated patient visits depicting common childhood illnesses were employed to request antibiotics without prescriptions. A simple random sampling was used to select medicine retail outlets within Addis Ababa city. Trained data collectors filled structured data forms (including antibiotic requested, reasons for denial of dispense and details enquired by pharmacist) shortly after each patient enactment. Multi-variable logistic regression analysis was employed to explore factors associated with over-the-counter sales of antibiotics.

Results

A total of 262 simulated encounters were surveyed. Of the 262 verbal antibiotic requests, 63.4% were dispensed. Close to 60% of encounters were accompanied by questions about a doctor's visit or the child's symptomatology while a past history of drug allergies was enquired in only 11.1% of visits. Over-the-counter dispensary was more likely when dispenser queried about symptoms was made (AOR: 2.412, 95%CI: 1.236, 4.706), for requests for more than one antibiotics (AOR: 2.988, 95%CI: 1.258, 7.095) and for simulated patient demands for oral antibiotics for children with acute diarrhea (AOR: 3.297, 95%CI: 1.248, 8.712) and parenteral antibiotics for those reported to receive in-patient care for pneumonia (4.516, 95% CI: 1.720, 11.857).

Conclusions

The prevalence of providing antibiotics over-the-counter for pediatric illnesses in Addis Ababa is markedly high. Further studies into factors encouraging this malpractice are required. Enhancing education of personnel dispensing antibiotics and strict enforcement of national regulations are needed.

High prevalence and characterization of extended-spectrum ß-lactamase producing Enterobacteriaceae in Chadian hospitals

Background

Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) represent a major problem in the management of nosocomial infections. However, ESBL-PE are not systematically monitored in African countries. The aim of this study was to determine ESBL-PE prevalence in patients from three hospitals in N’Djamena, the capital city of Chad, and to characterize the genetic origin of the observed resistance.

Methods

From January to March 2017, 313 non-duplicate isolates were recovered from various clinical specimens obtained from 1713 patients in the three main hospitals of N’Djamena. Bacterial species were identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry. Susceptibility to 28 antibiotics was tested using the disk diffusion method on Müller-Hinton agar, and ESBL production was confirmed with the double-disc synergy test. The most prevalent ESBL genes associated with the observed resistance were detected using multiplex PCR followed by double-stranded DNA sequencing.

Results

Among the 313 isolates, 197 belonged to the Enterobacteriaceae family. The overall ESBL-PE prevalence was 47.72% (n = 94/197), with a higher rate among inpatients compared with outpatients (54.13% vs. 34.37%). ESBL-PE prevalence was highest in older patients (≥60 years of age). E. coli was the most common ESBL-producer organism (63.8%), followed by K. pneumoniae (21.2%). ESBL-PE were mainly found in urine samples (75%). The CTX-M-1 group was dominant (96.7% of the 94 ESBL-PE isolates, CTX-M-15 enzyme), followed by the CTX-M-9 group (4.1%). 86% of resistant isolates harbored more than one ESBL-encoding gene. ESBL production was also associated with the highest levels of resistance to non-β-lactam drugs.

Conclusions

The prevalence of ESBL-PE harboring resistant genes encoding ESBLs of the CTX-M-1 group was high (48%) among clinical isolates of three main hospitals in Chad, suggesting an alarming spread of ESBL-PE among patients.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3838-1) contains supplementary material, which is available to authorized users.

Antibiotic prescribing in paediatric inpatients in Ghana: a multi-centre point prevalence survey

BACKGROUND

Excessive and inappropriate use of antibiotics in hospitalised patients contributes to the development and spread of antibiotic resistance. Implementing a stewardship programme to curb the problem requires information on antibiotic use. This study describes a multicentre point prevalence of antibiotic use among paediatric inpatients in Ghana.

METHODS

Data were extracted from a multicentre point prevalence survey of hospital acquired infections in Ghana. Data were collected between September 2016 and December 2016 from ten hospitals through inpatient folder and chart reviews using European Centre for Disease Control (ECDC) adapted data collection instrument. From each site, data were collected within a 12-h period (8 am to 8 pm) by a primary team of research investigators and a select group of health professionals from each participating hospital.

RESULTS

Among 716 paediatric inpatients, 506 (70.6%; 95% confidence interval (CI): 67.2 to 74.0%) were on antibiotics. A significant proportion of antibiotics (82.9%) was prescribed for infants compared to neonates (63.9%) and adolescents (60.0%). The majority of patients (n = 251, 49.6%) were prescribed two antibiotics at the time of the survey. The top five classes of antibiotics prescribed were third generation cephalosporins (n = 154, 18.5%) aminoglycosides (n = 149, 17.9%), second generation cephalosporins (n = 103,12.4%), beta lactam resistant penicillins (n = 83, 10.0%) and nitroimidazoles (n = 82, 9.9%). The majority of antibiotics (n = 508, 61.0%) were prescribed for community acquired infections. The top three agents for managing community acquired infections were ceftriaxone (n = 97, 19.1%), gentamicin (n = 85, 16.7%) and cefuroxime (n = 73, 14.4%).

CONCLUSION

This study points to high use of antibiotics among paediatric inpatients in Ghana. Cephalosporin use may offer an important target for reduction through antibiotic stewardship programmes.

Prevalence of extended-spectrum-β-lactamase-producing Enterobacteriaceae: first systematic meta-analysis report from Pakistan

Background

South-Asia is known as a hub for multidrug-resistant (MDR) bacteria. Unfortunately, proper surveillance and documentation of MDR pathogens is lacking in Pakistan. The alarming increase in the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is a serious problem. From this perspective, we analysed published data regarding ESBL-producing Enterobacteriaceae in different regions of Pakistan.

Methods

A meta-analysis was performed to determine the prevalence of ESBL-producing Enterobacteriaceae in Pakistan. A Web-based search was conducted in electronic databases, including PubMed, Scopus and PakMedi Net (for non-indexed Pakistani journals). Articles published (in either indexed or non-indexed journals) between January 2002 and July 2016 were included in the study. Relevant data were extracted, and statistical analysis was performed using the Metaprop command of STATA version 14.1.

Results

A total of 68 studies were identified from the electronic data base search, and 55 of these studies met our inclusion criteria. Pakistan’s overall pooled proportion of ESBL-producers was 0.40 (95% CI: 0.34–0.47). The overall heterogeneity was significant (I2 = 99.75%, p < 0.001), and significant ES = 0 (Z = 18.41, p < 0.001) was found. OXA, SHV, TEM and CTX-M were the most commonly found gene variants for ESBLs in these studies.

Conclusion

The prevalence of ESBL-producing Enterobacteriaceae is high in Pakistan. Little is known about the annual frequency of ESBLs and their prevalence in different provinces of Pakistan. No data are available regarding ESBL frequency in Baluchistan. This underscores an urgent demand for regular surveillance to address this antimicrobial resistance problem. Surveillance to better understand the annual ESBL burden is crucial to improve national and regional guidelines.

Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis

INTRODUCTION

Despite evidence of the high prevalence of antibiotic resistant infections in developing countries, studies on the clinical and economic impact of antibiotic resistance (ABR) to inform interventions to contain its emergence and spread are limited. The aim of this study was to analyze the published literature on the clinical and economic implications of ABR in developing countries.

METHODS

A systematic search was carried out in Medline via PubMed and Web of Sciences and included studies published from January 01, 2000 to December 09, 2016. All papers were considered and a quality assessment was performed using the Newcastle-Ottawa quality assessment scale (NOS).

RESULTS

Of 27 033 papers identified, 40 studies met the strict inclusion and exclusion criteria and were finally included in the qualitative and quantitative analysis. Mortality was associated with resistant bacteria, and statistical significance was evident with an odds ratio (OR) 2.828 (95%CI, 2.231-3.584; p = 0.000). ESKAPE pathogens was associated with the highest risk of mortality and with high statistical significance (OR 3.217; 95%CIs; 2.395-4.321; p = 0.001). Eight studies showed that ABR, and especially antibiotic-resistant ESKAPE bacteria significantly increased health care costs.

CONCLUSION

ABR is associated with a high mortality risk and increased economic costs with ESKAPE pathogens implicated as the main cause of increased mortality. Patients with non-communicable disease co-morbidities were identified as high-risk populations.

Correlates of multi-drug non-susceptibility in enteric bacteria isolated from Kenyan children with acute diarrhea

BACKGROUND

Reduced antimicrobial susceptibility threatens treatment efficacy in sub-Saharan Africa, where data on the burden and correlates of antibiotic resistance among enteric pathogens are limited.

METHODS

Fecal samples from children aged 6 mos-15 yrs presenting with acute diarrhea in western Kenya were cultured for bacterial pathogens. HIV-uninfected children with identified Shigella or Salmonella species or pathogenic Escherichia coli (EPEC, ETEC, EAEC or EIEC) were included in this cross-sectional sub-study. Non-susceptibility to ampicillin, ceftriaxone, ciprofloxacin, cotrimoxazole, and tetracycline was determined using MicroScan Walkaway40 Plus. Multivariable log-binomial regression was used to identify correlates of multi-drug non-susceptibility (MDNS, non-susceptibility to ≥ 3 of these antibiotics).

RESULTS

Of 292 included children, median age was 22.5 mos. MDNS was identified in 62.5% of 318 isolates. Non-susceptibility to cotrimoxazole (92.8%), ampicillin (81.3%), and tetracycline (75.0%) was common. Young age (6-24 mos vs. 24-59 mos adjusted prevalence ratio [aPR] = 1.519 [95% confidence interval: 1.19, 1.91]), maternal HIV (aPR = 1.29 [1.01, 1.66]); and acute malnutrition (aPR = 1.28 [1.06, 1.55]) were associated with higher prevalence of MDNS, as were open defecation (aPR = 2.25 [1.13, 4.50]), household crowding (aPR = 1.29 [1.08, 1.53]) and infrequent caregiver hand-washing (aPR = 1.50 [1.15, 1.95]).

CONCLUSIONS

Young age, HIV exposure, acute malnutrition and poor sanitation may increase risk of antibiotic non-susceptible enteric pathogen infections among children in Kenya.

Bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae among patients with malignancy: a systematic review and meta-analysis

Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are an increasing cause of resistant infections among patients with malignancy. This study sought to estimate the prevalence of bloodstream infections (BSIs) caused by ESBL-PE in this population and to examine regional and temporal differences. The PubMed and EMBASE databases (to 30 April 2016) were searched to identify studies reporting ESBL-PE BSI rates among patients with malignancies. Of 593 non-duplicate reports, 22 studies providing data on 5650 BSI cases satisfied the inclusion criteria. Among all BSIs the pooled prevalence of ESBL-PE was 11% (95% CI 8-15%) and among Gram-negative BSIs it was 21% (95% CI 16-27%). Among patients with haematological malignancies, the pooled ESBL-PE prevalence was 11% (95% CI 8-15%), whereas no studies providing specific data on patients with solid tumours were identified. Stratifying per geographic region, the pooled prevalence was 7% each in Europe (95% CI 5-11%), the Eastern Mediterranean region (95% CI 4-11%) and South America (95% CI 2-14%), 10% in the Western Pacific region (95% CI 4-19%) and 30% in Southeast Asia (95% CI 18-44%). Importantly, there was a 7.1% annual increase in the ESBL-PE incidence (P = 0.004). Overall, ca. 1 in 10 BSIs in patients with malignancy is caused by ESBL-PE and in some areas this rate can be as high as 1 in 3 cases. Additionally, the incidence of these resistant infections is rising. These findings should be considered when selecting empirical antimicrobial therapy and should prompt strict adherence to antimicrobial stewardship.

Very high prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae in bacteriemic patients hospitalized in teaching hospitals in Bamako, Mali

The worldwide dissemination of extended-spectrum beta-lactamase producing Enterobacteriaceae, (ESBL-E) and their subset producing carbapenemases (CPE), is alarming. Limited data on the prevalence of such strains in infections from patients from Sub-Saharan Africa are currently available. We determined, here, the prevalence of ESBL-E/CPE in bacteriemic patients in two teaching hospitals from Bamako (Mali), which are at the top of the health care pyramid in the country. During one year, all Enterobacteriaceae isolated from bloodstream infections (E-BSI), were collected from patients hospitalized at the Point G University Teaching Hospital and the pediatric units of Gabriel Touré University Teaching Hospital. Antibiotic susceptibility testing, enzyme characterization and strain relatedness were determined. A total of 77 patients had an E-BSI and as many as 48 (62.3%) were infected with an ESBL-E. ESBL-E BSI were associated with a previous hospitalization (OR 3.97 95% IC [1.32; 13.21]) and were more frequent in hospital-acquired episodes (OR 3.66 95% IC [1.07; 13.38]). Among the 82 isolated Enterobacteriaceae, 58.5% were ESBL-E (20/31 Escherichia coli, 20/26 Klebsiella pneumoniae and 8/15 Enterobacter cloacae). The remaining (5 Salmonella Enteritidis, 3 Morganella morganii 1 Proteus mirabilis and 1 Leclercia adecarboxylata) were ESBL negative. CTX-M-1 group enzymes were highly prevalent (89.6%) among ESBLs; the remaining ones being SHV. One E. coli produced an OXA-181 carbapenemase, which is the first CPE described in Mali. The analysis of ESBL-E relatedness suggested a high rate of cross transmission between patients. In conclusion, even if CPE are still rare for the moment, the high rate of ESBL-BSI and frequent cross transmission probably impose a high medical and economic burden to Malian hospitals.