Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients

Screening for nasal carriage of Staphylococcus (S.) aureus reduces the risk of S. aureus peritonitis in patients on peritoneal dialysis (PD)

INTRODUCTION

Screening for nasal carriage of Staphylococcus (S.) aureus is associated with a reduction of peritoneal dialysis (PD)-related infections, but conflicting results have questioned the benefit of this practice. This study evaluated the clinical effectiveness of the screening program for nasal carriage of S. aureus in reducing the peritonitis rate in the PD population.

METHODS

A single-center retrospective study was conducted on all patients on PD diagnosed with peritonitis from 1999 to 2023. From 2011, screening for S. aureus with nasal swabs was implemented in our program. It was performed before the start of PD and in any case of peritonitis. Consequently, the study period was divided into pre-screening (1999-2010) and screening (2011-2023) phases.

RESULTS

The study included 195 patients who experienced 345 peritonitis episodes. Median age was 67 years. The overall peritonitis rate was 0.21 episodes/patient-year. Post-screening, the S. aureus peritonitis rate decreased significantly from 0.036 to 0.009 episodes/patient-year (P < 0.001). The screening did not reduce the total episodes of peritonitis (0.23 vs. 0.19 episodes/patient-year). Indeed, the cumulative peritonitis rate difference between the two phases was not significant (P = 0.31). The screening of previously decolonized patients with S. aureus peritonitis showed that 50% of them were colonized by S. aureus and that recolonization frequently occured in this population. Multivariate regression analysis showed that S. aureus screening was the only protective measure to reduce the risk of S. aureus peritonitis (OR, 0.36; CI95% 0.14-0.91; P = 0.03).

CONCLUSIONS

In our center, screening for nasal carriage of S. aureus significantly reduced the incidence of S. aureus peritonitis but did not impact the overall peritonitis rate. Recolonization is a real event that warrants a better preventive strategy.

Early cytokine signatures and clinical phenotypes discriminate persistent from resolving MRSA bacteremia

BACKGROUND

Staphylococcus aureus bacteremia (SAB) is a prevalent life-threatening infection often caused by methicillin-resistant S. aureus (MRSA). Up to 30% of SAB patients fail to clear infection even with gold-standard anti-MRSA antibiotics. This phenomenon is termed antibiotic-persistent MRSA bacteremia (APMB). The mechanisms driving APMB are complex and involve host phenotypes significantly impacting the immune response. Thus, defining early immune signatures and clinical phenotypes that differentiate APMB from antibiotic resolving (AR)MB could aid therapeutic success.

METHODS

We assessed 38 circulating cytokines and chemokines using affinity proteomics in 74 matched pairs of vancomycin-treated SAB cases identified as ARMB or APMB after 5 days of blood culture.

RESULTS

Unsupervised hierarchical clustering segregated APMB from ARMB based on differential levels of IL-10, IL-12p40, IL-13, CCL4, and TGFα. Additionally, CXCL1, CCL22 and IL-17A significantly differed between APMB and ARMB when correlated with diabetes, dialysis, metastatic infection, or cardiac vegetation. Combining immune signatures with these relevant clinical phenotypes sharply increased accuracy of discriminating APMB outcome to 79.1% via logistic regression modeling. Finally, classification-regression tree analysis revealed explicit analyte thresholds associated with APMB outcome at presentation especially in patients with metastatic infection.

CONCLUSIONS

Collectively, this study identifies previously unrecognized cytokine and chemokine signatures that distinguish APMB and ARMB at presentation and in the context of host clinical characteristics associated with increased disease severity. Validation of a biomarker signature that accurately predicts outcomes could guide early therapeutic strategies and interventions to reduce risks of persistent SAB that are associated with worsened morbidity and mortality.

Impact of risk factors on the incidence of tunneled dialysis catheter infections: a systematic review and meta-analysis

INTRODUCTION

Tunneled dialysis catheters (TDCs) are important for hemodialysis in patients awaiting a permanent surgical solution, kidney transplantation or without feasible surgical access. Infection of a TDC is a common and severe complication, which often requires removal of the TDC and causes high morbidity and mortality. To date, several risk factors for TDC infections have been reported. This systematic review and meta-analysis aim to provide an overview of currently known risk factors.

METHODS

A systematic literature search was conducted, including all studies describing patient-, catheter-, and dialysis-related risk factors for TDC infections. In case sufficient data was available for a risk factor, a meta-analysis with random effects model was performed.

RESULTS

Out of 1273 studies, 30 were included describing a total of 71 risk factors. A meta-analysis was conducted for 26 risk factors. The average incidence of TDC infections was 1.16 ± 0.70/1000 catheter days. Diabetes (odds ratio, OR 1.96), coronary artery disease (OR 2.16), peripheral artery disease (OR 2.28), history of sepsis (OR 2.79), and the number of prior TDCs (OR 1.24) were the most significant risk factors for infection.

CONCLUSION

Several risk factors are associated with increased TDC infection rates. Most of these risk factors are also linked with infection in other populations and most likely reflect the general frailty of hemodialysis patients. The association between many risk factors and TDC infections was often unclear due to the low number of studies available. Additional large cohort studies are necessary to demonstrate the relevance of these risk factors.

Prevalence of Nasal Staphylococcus aureus Carriage in Patients Undergoing Hemodialysis and Assessment of Risk Factors: A Cross-Sectional Study of Outpatients at a University Hospital

Background/Objectives: Infection poses a significant threat of mortality in patients with chronic kidney disease (CKD) undergoing hemodialysis. Staphylococcus aureus (S. aureus) is a common etiological agent, with prior nasal colonization identified as a risk factor for infection. The aim of the present cross-sectional study was to determine the prevalence of nasal S. aureus carriage among patients with CKD undergoing dialysis at a university hospital and identify potential factors associated with colonization. Methods: Nasal swabs were obtained, and bacterial isolates were identified using matrix-assisted laser desorption/ionization time-of-flight spectrometry and antibiogram testing with the Vitek 2 system. Demographic and clinical data were collected for the investigation of risk factors associated with colonization. Results: Among the 96 patients analyzed, 34 were carriers of S. aureus. Among these carriers, three (8.8%) harbored oxacillin-resistant strains. More than half of the S. aureus strains exhibited resistance to clindamycin but susceptibility to oxacillin. Colonization was associated with age and the use of corticosteroids/immunosuppressants. Conclusions: The prevalence of nasal S. aureus carriage was high among patients undergoing dialysis at the university hospital, exceeding that found in the general population. Nasal colonization by S. aureus was linked to corticosteroid use and age. Understanding factors associated with S. aureus nasal colonization in patients on dialysis can assist healthcare providers in preventing the spread of infection and cross-contamination, while reducing risk in this population.

Analysis of the dynamics of transition from non-colonization to colonization and Staphylococcus aureus bacteremia in hemodialysis patients using Markov models

Background

Hemodialysis patients are frequently colonized by Staphylococcus aureus, leading to severe infections with high mortality rates. However, little is known about transition from non-colonization to colonization or bacteremia over time. The aim was to analyze the behavior of S. aureus colonization, identifying the probability of transition from non-colonized to colonized state or bacteremia, and the influence of specific covariates.

Methods

The study was conducted in a dialysis unit associated with a tertiary care hospital in Medellín between October 2017 and October 2019. An initial measurement was taken to evaluate S. aureus colonization, and follow-up measurements were performed 2 and 6 months later. Bacteremia evolution was monitored for 12 months. A two-state recurrent continuous-time Markov model was constructed to model transition dynamics from non-colonization to S. aureus colonization in hemodialysis patients. Subsequently, the model was applied to a third state of bacteremia.

Results

Of 178 patients on hemodialysis, 30.3% were colonized by S. aureus. Transition intensity from non-colonization to colonization was three times higher (0.21; CI: 0.14-0.29) than from colonization to non-colonization (0.07; CI: 0.05-0.11). The colonization risk increased in patients with previous infections (HR: 2.28; CI: 0.78-6.68), hospitalization (HR: 1.29; CI: 0.56-2.99) and antibiotics consumption (HR: 1.17; CI: 0.53-2.58). Mean non-colonized state duration was 10.9 months, while in the colonized state was 5.2 months. In the 3-state model, it was found that patients colonized were more likely to develop S. aureus infection (13.9%).

Conclusion

A more likely transition from non-colonization to colonization was found, which increases with factors such as previous infection. In addition, the development of bacteremia was more likely in colonized than in non-colonized patients. These results underline the importance of surveillance and proper management of S. aureus colonization to prevent serious complications, such as bacteremia, and improve prognosis in this vulnerable population.

The impact of colonization by multidrug resistant bacteria on graft survival, risk of infection, and mortality in recipients of solid organ transplant: systematic review and meta-analysis

BACKGROUND

The Global increase in colonization by multidrug-resistant (MDR) bacteria poses a significant concern. The precise impact of MDR colonization in solid organ transplant recipients (SOTR) remains not well established.

OBJECTIVES

To assess the impact of MDR colonization on SOTR's mortality, infection, or graft loss.

METHODS AND DATA SOURCES

Data from PROSPERO, OVID Medline, OVID EMBASE, Wiley Cochrane Library, ProQuest Dissertations, Theses Global, and SCOPUS were systematically reviewed, spanning from inception until 20 March 2023. The study protocol was registered with PROSPERO (CRD42022290011) and followed the PRISMA guidelines. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, INTERVENTIONS, AND ASSESSMENT OF RISK OF BIAS: Cohorts and case-control studies that reported on adult SOTR colonized by Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase (ESBL) or carbapenem-resistant Enterobacteriaceae. (CRE), or MDR-pseudomonas, and compared to noncolonized, were included. Two reviewers assessed eligibility, conducted a risk of bias evaluation using the Newcastle-Ottawa Scale, and rated certainty of evidence using the GRADE approach.

METHODS OF DATA SYNTHESIS

We employed RevMan for a meta-analysis, using random-effects models to compute pooled odds ratios (OR) and 95% confidence intervals (CI). Statistical heterogeneity was determined using the I2 statistic.

RESULTS

15,202 SOTR (33 cohort, six case-control studies) were included, where liver transplant and VRE colonization (25 and 14 studies) were predominant. MDR colonization significantly increased posttransplant 1-year mortality (OR, 2.35; 95% CI, 1.63-3.38) and mixed infections (OR, 10.74; 95% CI, 7.56-12.26) across transplant types (p < 0.001 and I2 = 58%), but no detected impact on graft loss (p 0.41, I2 = 0). Subgroup analysis indicated a higher association between CRE or ESBL colonization with outcomes (CRE: death OR, 3.94; mixed infections OR, 24.8; ESBL: mixed infections OR, 10.3; no mortality data) compared to MRSA (Death: OR, 2.25; mixed infection: OR, 7.75) or VRE colonization (Death: p 0.20, mixed infections: OR, 5.71).

CONCLUSIONS

MDR colonization in SOTR, particularly CRE, is associated with increased mortality. Despite the low certainty of the evidence, actions to prevent MDR colonization in transplant candidates are warranted.

Infective Endocarditis in Patients with End-Stage Renal Disease on Dialysis: Epidemiology, Risk Factors, Diagnostic Challenges, and Management Approaches

Infective endocarditis (IE) poses a significant clinical challenge, especially among patients with end-stage renal disease (ESRD) undergoing dialysis, and is associated with high morbidity and mortality rates. This review provides a contemporary discussion of the epidemiology, risk factors, diagnostic challenges, and management strategies for IE among ESRD patients, including a literature review of recent studies focused on this vulnerable population. The review highlights the multifactorial nature of IE risk in ESRD patients, emphasizing the roles of vascular access type, dialysis modality, and comorbid conditions. It also explores the diagnostic utility of different imaging modalities and the importance of a multidisciplinary approach in managing IE, including both medical and surgical interventions. The insights from this review aim to contribute to the improvement of patient outcomes through early recognition, appropriate antimicrobial therapy, and timely surgical intervention when necessary.

Colonisation with multidrug-resistant organisms among dialysis patients at Universitas Academic Hospital

Background

While most infections with multidrug-resistant organisms (MDROs) affect colonised people, there is limited evidence on MDRO colonisation in South African dialysis patients.

Objectives

This study evaluated the prevalence of MDRO colonisation among dialysis patients, the resistance patterns of each MDRO and the risk factors for colonisation.

Method

Rectal and nasal swabs were collected from dialysis patients who consented to participate in a 5-month study to identify selected MDROs (April 2021 - August 2021). Specimens were cultured on selected chromogenic media. Data collected included demographics, clinical information from medical records and laboratory results.

Results

Multidrug-resistant organisms were isolated from 17 (23.9%) of the 71 enrolled participants. Of the 23 MDRO strains from rectal swabs (n = 71), extended-spectrum beta-lactamase-producing Enterobacterales accounted for 21.1% (15/71), vancomycin-resistant enterococci 2.8% (n = 2/71) and carbapenem-resistant Enterobacterales 4.2% (n = 3/71). Klebsiella pneumoniae (65.2%, n = 15/23) was the most prevalent MDRO. More than 80% resistance to trimethoprim and sulfamethoxazole, cefotaxine, and ciprofloxacin was noted. Significant risk factors included previous hospitalisation, proton pump inhibitor use and antibiotic exposure in the past 6 months.

Conclusion

Multidrug-resistant organisms' carriage was high in our dialysis population. The infection prevention and control measures need to be revised and strengthened.

Contribution

This study falls within the scope of the SAJID journal as it is the first within sub-Sahara Africa to report that approximately one-fifth of dialysis patients were colonised with MDRO, which is a significant risk for MDRO infections.

Staphylococcus aureus nasal colonization and susceptibility profile to antimicrobials in hemodialysis patients using a protocol of seven collections

BACKGROUND

Patients colonized with Staphylococcus aureus in their nasal passages have a higher risk of acquiring infection, especially if they are immunocompromised or have comorbidities such as chronic renal failure undergoing hemodialysis (HD).

OBJECTIVE

This study aimed to report the prevalence of nasal carriage of S. aureus among HD patients utilizing a seven-week sampling protocol and to assess the susceptibility of these isolates to various antimicrobial agents.

METHODS

Over seven consecutive weeks, nasal swab samples were collected from 47 HD patients, resulting in a total of 329 samples. The microorganisms were identified using biochemical methods and subjected to antimicrobial susceptibility testing via disk diffusion and microdilution techniques.

RESULTS

Out of all the patients analyzed, 25 individuals (53.19%) were found to be colonized by S. aureus, with 21 of them displaying intermittent colonization. Additionally, 38% showed positive results for S. aureus in only the 6th or 7th week of sampling. Within the 58 isolates, 17.2% (n=10) exhibited methicillin (oxacillin)-resistance and 25.86% (n=15) displayed elevated vancomycin MIC values (2 µg/ml). Based on the results, daptomycin and gentamicin were found to be effective treatment options. However, 31% of the isolates (n=18) exhibited a MIC of 1 µg/ml for daptomycin.

CONCLUSION

Over half of the patients were colonized by S. aureus, but mostly on an intermittent basis. The identification of oxacillin resistance and high vancomycin and daptomycin MICs serve as warnings for possible future complications in managing bacteremia caused by S. aureus in these patients.

Genomic Characterization of Methicillin-Susceptible Staphylococcus aureus Carriage in Patients on Home Parenteral Nutrition and Their Caregivers

In this prospective study, patients on home parenteral nutrition were twice as likely to be colonized with Staphylococcus aureus if their caregivers were carriers. Among S. aureus-positive patients and their caregivers, molecular analysis showed 68% genetically related strains. Despite decolonization, genetically related strains reappeared in 70% of patients.

Predictors for multidrug-resistant organisms (MDROs) carriage in haemodialysis patients

Introduction

Infections in haemodialysis (HD) patients are an important cause of morbidity, hospitalization, and mortality. Patients undergoing HD are more prone to develop bacterial infections by multidrug-resistant organisms (MDROs).

Objectives

This study is aimed to detect MDROs colonization in HD patients and its associated risk factors and outcome.

Methodology

A total of 62 nasal swabs and 124 rectal swabs were collected from 62 patients coming to the haemodialysis unit from of March to May 2021 and were further screened for MRSA, VRE and CRE.

Results

Out of 62 patients, 22.59% showed the presence of methicillin-resistant staphylococcus aureus (MRSA) while VRE was present in four patients (4/62). CRE was found as 24.2% (15/62). Duration of dialysis was found as a significant risk factor-associated MRSA carriage, Whereas Charlson index and drug and medication were found as significant risk factor for VRE carriage.

Discussion & Conclusion

HD patients are particularly vulnerable to life threatening infections. Therefore, continuous epidemiological surveillance for these MDROs, including genotypic analysis and implementation of adequate decolonization strategies, is crucial and will reduce the possibility of autoinfection as well as disrupt transmission of multi-resistant isolates to others.

Practices, Knowledge, and Attitudes of Nephrologists Towards Prescribing and Monitoring Vancomycin at Dialysis Centers

BACKGROUND

Vancomycin dosing protocols are varied in the literature for hemodialysis patients. This study sought to determine nephrologists' practices, knowledge, attitudes, and barriers toward prescribing and monitoring vancomycin at dialysis centers.

METHODS

A cross-sectional and multi-center study was conducted in Kuwait using a validated self-administered questionnaire among 168 nephrologists. Descriptive and comparative analyses were performed using SPSS (version 28).

RESULTS

The response rate was 75% (n = 126). Over half of nephrologists frequently prescribed a vancomycin loading dose of 1000 mg (53.2%) and a maintenance dose of 500 mg (51.6%) to all patients. Their overall median (IQR) percentage knowledge about the therapeutic monitoring of vancomycin was 66.7% (33.3) and was found to be higher in nephrologists aged ≤ 40 years and in registrars/senior registrars (p < 0.05). Their overall median (IQR) attitude score was 4.0 (1.0) [positive attitude]. Nephrologists with > 15 years of practice experience expressed higher attitudes (p < 0.05). The top two perceived barriers were a lack of clear local hospital/national guidelines (60.3%) for vancomycin dosing in dialysis and inconsistencies among different dosing references and guidelines (51.6%).

CONCLUSION

Findings showed that nephrologists have varying practices, moderate knowledge, and positive attitudes toward prescribing and monitoring vancomycin and highlight the need for interventions to overcome the perceived barriers.

Long-Term Proton Pump Inhibitor Therapy Increases the Risk of Infection in Patients with Incident Hemodialysis

BACKGROUND

Infection is one of the most common causes of death in patients with chronic kidney disease (CKD). Proton pump inhibitors (PPIs) are not only widely used in patients with CKD but also represent a known risk factor for infection in the general population. Here, we investigated associations between PPIs and infection events in patients with incident hemodialysis.

METHODS

We analyzed data from 485 consecutive patients with CKD who started hemodialysis at our hospital between January 2013 and December 2019. We analyzed associations between infection events and long-term (≥6 months) PPI use before and after propensity score-matched analysis.

RESULTS

Of the 485 patients, PPIs were administered to 177 patients (36.5%). During 24 months of follow-up, infection events occurred in 53 patients (29.9%) with PPIs and 40 patients (13.0%) without PPIs (p < 0.001). Patients with PPIs had a significantly higher cumulative incidence rate of infection events than those without PPIs (hazard ratio [HR] 2.13, 95% confidence interval [CI]: 1.36-3.32; p < 0.001). Even after propensity score-matched analysis (132 patients matched in each), the rate of infection events was higher for patients with PPIs (28.8% vs. 12.1%, HR 2.88, 95% CI: 1.61-5.16; p < 0.001). Similar results were obtained for severe infection events in both unmatched (14.1% vs. 4.5%, HR 2.97, 95% CI: 1.47-6.00; p = 0.002) and propensity score-matched analyses (14.4% vs. 3.8%, HR 4.54, 95% CI: 1.85-11.13; p < 0.001).

CONCLUSIONS

In patients with incident hemodialysis, long-term PPI use increases the risk of infection. Clinicians should be wary of unnecessarily prolonging PPI therapy.

Randomized clinical trial: Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition

BACKGROUND & AIMS

Staphylococcus aureus decolonization has proven successful in prevention of S. aureus infections and is a key strategy to maintain venous access and avoid hospitalization in patients receiving home parenteral nutrition (HPN). We aimed to determine the most effective and safe long-term S. aureus decolonization regimen.

METHODS

A randomized, open-label, multicenter clinical trial was conducted. Adult intestinal failure patients with HPN support and carrying S. aureus were randomly assigned to a 'continuous suppression' (CS) strategy, a repeated chronic topical antibiotic treatment or a 'search and destroy' (SD) strategy, a short and systemic antibiotic treatment. Primary outcome was the proportion of patients in whom S. aureus was totally eradicated during a 1-year period. Secondary outcomes included risk factors for decolonization failure and S. aureus infections, antimicrobial resistance, adverse events, patient compliance and cost-effectivity.

RESULTS

63 participants were included (CS 31; SD 32). The mean 1-year S. aureus decolonization rate was 61% (95% CI 44, 75) for the CS group and 39% (95% CI 25, 56) for the SD group with an OR of 2.38 (95% CI 0.92, 6.11, P = 0.07). More adverse effects occurred in the SD group (P = 0.01). Predictors for eradication failure were a S. aureus positive caregiver and presence of a (gastro)enterostomy.

CONCLUSION

We did not demonstrate an increased efficacy of a short and systemic S. aureus decolonization strategy over a continuous topical suppression treatment. The latter may be the best option for HPN patients as it achieved a higher long-term decolonization rate and was well-tolerated (NCT03173053).

The relationship between renal functions and multi-drug resistant organisms in patients with ventilator-associated pneumonia

Objective: Despite the increase in the frequency of multi-drug resistant organism (MDRO) colonisation and infection in dialysis patients, it is not well known whether the risk of multi-drug resistant (MDR) pneumonia increases in mild-to-severe chronic kidney disease patients not undergoing dialysis. Therefore, we aimed to evaluate the relationship between renal functions and the risk of MDR ventilator-associated pneumonia (VAP) and the specific microbial pattern. Patients and Methods: A total of 133 patients who developed VAP were divided according to their renal function into two groups, an estimated glomerular filtration rate of (eGFR) ≥ 60 mL/ min/1.73 m2 (high eGFR, n=65) and eGFR < 60 mL/min/1.73 m2 (low eGFR, n=68). Results: The low eGFR group presented a significantly high MDRO ratio (p

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evolving peritoneal dialysis care in Chinese mainland from 2010 to 2020: Comparison data from two surveys

INTRODUCTION

Along with the peritoneal dialysis (PD)-favored policy in China and the implementation of more comprehensive PD management, PD has evolved in Chinese mainland over the last decade. Despite the existence of national registries and several provincial epidemiological descriptive studies, there was almost no national research on the changing trajectory in PD population. A comparison study, based on two national surveys that were 10 years apart, was conducted to reveal the evolvement of PD care in Chinese mainland.

METHODS

Two national surveys have been done respectively in 2010 and 2020 to capture the epidemiological status, application of different modalities, management of perioperative infection, and long-term complications among PD patients.

RESULTS

In the study with 730 participating hospitals (n = 14,912 PD patients) in 2010 and 746 hospitals (n = 101,537) in 2020, prevalent PD patients have increased in the past 10 years with increased numbers of PD patients in both secondary (average 5 ± 16 vs. 43 ± 41, p < 0.01) and tertiary hospitals (32 ± 53 vs. 153 ± 215, p < 0.01). Automated PD has been accessible in 0.4% of all hospitals, only in tertiary centers in 2010 and its application increased to 51% in 2020. PD centers have become more engaged in PD catheter placement, treated properly for the PD-related infection, and carried out the follow-up in compliance with the national protocols.

CONCLUSIONS

Our study indicates that over the past decade, the prevalent PD population has quickly expanded with increased APD availability in Chinese mainland. The management of PD patients has become better conforming to the guidelines and long-term follow-up of patients have remained stable. Further studies are warranted to evaluate whether the rapidly changing paradigm of PD could translate into the socio-economic benefits in the society.

Chronic Kidney Disease-An Underestimated Risk Factor for Antimicrobial Resistance in Patients with Urinary Tract Infections

(1) Background: Chronic kidney disease (CKD), as well as antimicrobial resistance (AMR) represent major global health problems, with important social and economic implications. It was reported that CKD is a risk factor for antimicrobial resistance, but evidence is scarce. In addition, CKD is recognized to be a risk factor for complicated urinary tract infections (UTIs). (2) Methods: We conducted an observational study on 564 adult in-hospital patients diagnosed with urinary tract infections. The aim of the study was to identify the risk factors for AMR, as well as multiple drug resistance (MDR) and the implicated resistance patterns. (3) Results: The mean age was 68.63 ± 17.2 years. The most frequently isolated uropathogens were Escherichia coli strains (68.3%) followed by Klebsiella species (spp. (11.2%). In 307 cases (54.4%)), the UTIs were determined by antibiotic-resistant bacteria (ARBs) and 169 cases (30%) were UTIs with MDR strains. Increased age (≥65) OR 2.156 (95% CI: 1.404−3.311), upper urinary tract obstruction OR 1.666 (1.083−2.564), indwelling urinary catheters OR 6.066 (3.919−9.390), chronic kidney disease OR 2.696 (1.832−3.969), chronic hemodialysis OR 4.955 (1.828−13.435) and active malignancies OR 1.962 (1.087−3.540) were independent risk factors for MDR UTIs. In a multivariate logistic regression model, only indwelling urinary catheters (OR 5.388, 95% CI: 3.294−8.814, p < 0.001), CKD (OR 1.779, 95% CI: 1.153−2.745, p = 0.009) and chronic hemodialysis (OR 4.068, 95% 1.413−11.715, p = 0.009) were risk factors for UTIs caused by MDR uropathogens. (4) Conclusions: CKD is an important risk factor for overall antimicrobial resistance, but also for multiple-drug resistance.

Staphylococcus aureus nasal carriage and bloodstream infection among conventional hemodialysis patients in Thailand: a prospective multicenter cohort study

Objective

Staphylococcus aureus nasal carriage screening among hemodialysis patients is not standard practice in Thailand, because of data lacking regarding prevalence and correlation with subsequent infection. We aimed to investigate the prevalence of S. aureus nasal carriage and its association with bloodstream infection among hemodialysis patients. In this prospective multicenter cohort study, participants were screened for S. aureus nasal carriage over 2 consecutive weeks. Incidence of S. aureus bloodstream infection over the next 12 months was observed.

Results

The prevalence of S. aureus nasal carriage was 11.67%. Incidence of S. aureus bacteremia among participants with and without S. aureus nasal carriage were 7.1% and 3.8%, respectively. The odds ratio for nasal carriage and subsequent bacteremia was 1.96 (95% CI 0.04–21.79; p = 0.553). Survival analysis showed that time to bacteremia among participants in the two groups did not significantly differ (p = 0.531). Prevalence of S. aureus nasal carriage among hemodialysis patients in Thailand was low. Patients presenting with S. aureus nasal carriage did not have increased risk of S. aureus bacteremia after 12-month follow-up. Nasal S. aureus screening and decolonization should not be encouraged in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06185-y.

Worldwide prevalence of maternal methicillin-resistant Staphylococcus aureus colonization: A systematic review and meta-analysis

Methicillin-resistant Staphylococcus aureus (MRSA) infection during pregnancy can adversely influence the well-being of pregnant women, fetuses, and neonates. To our knowledge, there is no global data on the maternal prevalence of MRSA colonization. We conducted a systematic review and meta-analysis to estimate the global and regional prevalence rates of MRSA colonization among pregnant women. We searched international databases (i.e., MEDLINE/PubMed, EMBASE, Scopus, Web of Science collection, and SciELO) for studies published from inception to March 10, 2022. Observational population-based studies reporting MRSA colonization among pregnant women were eligible to be included. We utilized the random-effects meta-analyses to compute the pooled prevalence estimates of maternal colonization across studies at 95% confidence intervals (CIs). The heterogeneity was assessed by I² statistic and the Cochran's Q test. Subgroup and meta-regression analyses were used to adjust for potential sources of heterogeneity. The data source regarding maternal MRSA colonization included 55 studies from 24 countries and 110,654 pregnant women. The worldwide pooled prevalence for maternal MRSA colonization was 3.23% (95% CI, 2.40-4.17%), with the highest and lowest colonization rates for Africa (9.13%, 4.36-15.34%) and Europe (0.79%, 0.28-1.51%), respectively. We estimated that nearly 4.5 million pregnant women are colonized with MRSA worldwide. MRSA colonization rates were higher among black ethnicity, multiparous women, pregnant women with prior MRSA infection, women with lower personal hygiene, and those living in lower-income and human development indices countries or regions. MRSA colonizes substantial numbers of pregnant women worldwide, with varying prevalence rates in different regions; however, further investigations are needed to recognize regional differences. Our findings emphasized the need for prevention efforts against MRSA to reduce the health risks among women and newborns.

The lived experience of haemodialysis patients managed with transmission-based precautions for MDRO colonisation: A qualitative study

BACKGROUND

Patients undergoing haemodialysis colonised with multi-drug resistant organisms (MDROs) are commonly managed with transmission-based precautions (TBP) to prevent nosocomial transmission. TBP have been linked to mixed effects on patient psychological well-being and clinical care. This study was designed to report the lived experience of dialysis patients managed with TBP.

METHODS

A qualitative study of 15 patients undergoing haemodialysis managed with TBP was performed. Participants took part in individual semi-structured interviews. Data was analysed utilising an interpretive phenomenological approach.

RESULTS

Four themes were identified. 1. Communication of what MDRO screening meant, the results, and implications of MDRO positivity was perceived by many patients as insufficient and inconsistent. 2. Experiences of care in isolation were described, with both positive (privacy) and negative (reduced interaction) experiences identified. 3. Psychosocial and emotional responses including concern about health implications and stigma were reported, but also screening was described by some as increasing their perception of being cared for by health care workers, as they felt all health risks were being managed. 4. Confusion around perceived inconsistencies of management, particularly across different environments (eg hospital vs home) and staff.

CONCLUSION

TBP have complex positive and negative impacts on patients which should be considered when developing MDRO management policy and communication around such policy. Strategies to improve communication, patient and staff education, and remove (or explain) perceived inconsistencies of practice may reduce the negative consequences of TBP leading to improved delivery of quality, person-centred care.

Everybody nose: molecular and clinical characteristics of nasal colonization during active methicillin-resistant Staphylococcus aureus bloodstream infection

Background

Healthcare-associated infections pose a potentially fatal threat to patients worldwide and Staphylococcus aureus is one of the most common causes of healthcare-associated infections. S. aureus is a common commensal pathogen and a frequent cause of bacteremia, with studies demonstrating that nasal and blood isolates from single patients match more than 80% of the time. Here we report on a contemporary collection of colonizing isolates from those with methicillin-resistant S. aureus (MRSA) bloodstream infections to evaluate the diversity within hosts, and detail the clinical features associated with concomitant nasal colonization.

Methods

Swabs of the bilateral anterior nares were obtained from patients diagnosed with MRSA bacteremia. A single colony culture from the blood and an average of 6 colonies from the nares were evaluated for MRSA growth. For the nares cultures, we typed multiple isolates for staphylococcal protein A (spa) and derived the clonal complexes. Demographic and clinical data were obtained retrospectively from the electronic medical record system and analysed using univariate and multivariable regression models.

Results

Over an 11-month period, 68 patients were diagnosed with MRSA bloodstream infection, 53 were swabbed, and 37 (70%) were colonized with MRSA in the anterior nares. We performed molecular typing on 213 nasal colonies. Spa types and clonal complexes found in the blood were also detected in the nares in 95% of the cases. We also found that 11% of patients carried more than one clone of MRSA in the nares. Male sex and history of prior hospitalization within the past 90 days increased odds for MRSA colonization.

Conclusion

The molecular epidemiological landscape of colonization in the setting of invasive disease is diverse and defining the interplay between colonization and invasive disease is critical to combating invasive MRSA disease.

Secondary Immunodeficiency Related to Kidney Disease (SIDKD)-Definition, Unmet Need, and Mechanisms

Kidney disease is a known risk factor for poor outcomes of COVID-19 and many other serious infections. Conversely, infection is the second most common cause of death in patients with kidney disease. However, little is known about the underlying secondary immunodeficiency related to kidney disease (SIDKD). In contrast to cardiovascular disease related to kidney disease, which has triggered countless epidemiologic, clinical, and experimental research activities or interventional trials, investments in tracing, understanding, and therapeutically targeting SIDKD have been sparse. As a call for more awareness of SIDKD as an imminent unmet medical need that requires rigorous research activities at all levels, we review the epidemiology of SIDKD and the numerous aspects of the abnormal immunophenotype of patients with kidney disease. We propose a definition of SIDKD and discuss the pathogenic mechanisms of SIDKD known thus far, including more recent insights into the unexpected immunoregulatory roles of elevated levels of FGF23 and hyperuricemia and shifts in the secretome of the intestinal microbiota in kidney disease. As an ultimate goal, we should aim to develop therapeutics that can reduce mortality due to infections in patients with kidney disease by normalizing host defense to pathogens and immune responses to vaccines.

Skin Colonizers and Catheter Associated Blood Stream Infections in Incident Indian Dialysis Patients

Introduction

Skin colonization is a risk factor for multi-drug resistant (MDR) catheter-associated bloodstream infections (CABSI). This study aimed to determine the prevalence and spectrum of skin colonizing MDR organisms in incident HD patients and their correlation with CABSI.

Methods

This single-center prospective cohort study included consecutive adult incident HD patients who underwent tunneled or non-tunneled internal jugular vein HD catheter insertion between June 1, 2017 and October 31, 2017. Nasal, axillary, and exit site swabs were obtained prior to catheter insertion, at 14-21 days, and 28-35 days after catheter insertion.

Results

Forty-three patients (69.7% male, 32.5% diabetic) were included and provided baseline swabs, while 29 and 10 patients respectively were available for follow-up swabs. MDR bacterial colonization, MRSA colonization, and MDR gram-negative colonization on the baseline set of swabs were seen in 76.7%, 69.7%, and 9.3% patients respectively. Of the 29 patients with at least two consecutive sets of swabs, 79.3% showed persistent colonization by MDR gram-positive organisms, most commonly by MRSA. Six patients developed a CABSI during the follow-up period (incidence rate 3.7 per 1000 patient days), 83.4% were gram negative, and in only one instance (16.6%) was the bacterial strain identical to that which had previously colonized the skin.

Conclusions

Three-fourths of HD patients were colonized by MDR bacteria prior to HD initiation. Despite the majority being persistently colonized by MDR gram-positive organisms, CABSIs were predominantly gram negative.

Pathogens and Prognosis of Deep Neck Infection in End-Stage Renal Disease Patients

OBJECTIVES/HYPOTHESIS

To examine the pathogenic bacterial spectra and prognosis of deep neck infection (DNI) in end-stage renal disease (ESRD) patients.

STUDY DESIGN

Retrospective study.

METHODS

Patients diagnosed with DNI between 2004 and 2015 in Chang Gung Memorial Hospital were enrolled and divided into three groups, namely ESRD-DNI, chronic kidney disease (CKD)-DNI, and non-CKD-DNI. Differences in pathogenic bacteria, treatment, and prognosis were compared across the three groups.

RESULTS

The bacterial spectra differed among the three groups. The main three facultative anaerobic or aerobic bacteria causing ESRD-DNIs were methicillin-resistant Staphylococcus aureus (MRSA; 25.4%), methicillin-susceptible S. aureus (MSSA; 14.1%), and Klebsiella pneumoniae (KP; 12.7%). For CKD-DNIs, they were KP (23.5%), Viridans streptococci (VS; 23.5%), and MSSA (14.7%). For non-CKD-DNIs, they were VS (31.7%), KP (17.2%), and coagulase-negative staphylococci (8.0%). Compared with the other groups, the ESRD-DNI group had higher white blood cell and C-reactive protein levels, longer hospital stays, more frequent admissions to the intensive care unit, more mediastinal complications, and a significantly higher mortality rate.

CONCLUSIONS

The ESRD-DNI group exhibited more severe disease activity and higher mortality compared with those of the CKD-DNI and non-CKD-DNI groups. MRSA was the leading pathogen for patients with ESRD-DNI. Physicians must implement strategies for the early detection of MRSA to accurately prescribe antibiotics and prevent nosocomial transmission.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Native Vertebral Osteomyelitis in Patients with Staphylococcus aureus Bacteremia

BACKGROUND

The purpose of the study was to assess the epidemiology, risk factors and outcomes of native vertebral osteomyelitis (NVO) in patients with Staphylococcus aureus bacteremia (SAB).

METHODS

A retrospective institutional review was conducted at Mayo Clinic, Minnesota. Patients aged ≥ 18 years with SAB who developed NVO from January 1, 2006 to December 31, 2020 were included and 3-month follow-up data were abstracted. Data pertaining to patient demographics, risk factors and outcomes were recorded using REDCap. A 1:2 nested case-control analysis was performed, and controls were matched according to age, sex and year of SAB diagnosis.

RESULTS

A total of 103 patients had NVO. A majority (60.2%) of patients was male, with a median age of 62.0 years. Thirty-one (30.1%) cases were caused by methicillin-resistant S. aureus (MRSA). The lumbar spine was most commonly (57.6%) and the most commonly reported comorbid conditions included diabetes mellitus (36.9%) and coronary artery disease (27.2%). Mortality at three-month follow-up was 18.6%. Nested case-control analysis revealed that injection drug use (IDU) and tobacco consumption were significant risk factors associated with NVO, while chronic hemodialysis and chronic liver disease (CLD) were associated with a decreased risk of NVO.

CONCLUSIONS

Atherosclerotic vascular disease was prominent in our contemporary cohort with NVO in the setting of SAB. Diabetes mellitus, tobacco consumption, older age and male sex likely contributed to this profile. Because IDU was associated with NVO, an increased number of cases should be anticipated among patients with IDU given the ongoing opioid epidemic in the United States.

Post-Dialysis Parenteral Antimicrobial Therapy in Patients Receiving Intermittent High-Flux Hemodialysis

Patients with end-stage renal disease (ESRD) requiring intermittent hemodialysis (IHD) are at increased risk of infection, which represents a leading cause of mortality in this population. The use of additional vascular access devices such as peripherally inserted central catheters to treat such infections should be minimized in patients with ESRD requiring IHD in order to mitigate complications such as infection and thrombosis and to maintain venous patency for hemodialysis access. Intravenous antimicrobial dosing following IHD has the advantages of avoiding additional access devices and providing convenience for patients and providers. Vancomycin, cefazolin, and aminoglycosides have historically been regarded as the primary intravenous antimicrobials administered with IHD given their relatively low cost, convenient dosing, and longevity of clinical use. Despite this, a growing body of literature is evaluating the use of an expanded list of antimicrobials that may be employed using post-dialysis dosing for patients requiring IHD; however, the available data are largely limited to pharmacokinetic studies and small cohorts of infected patients or uninfected subjects. Post-dialytic dosing of intravenous antimicrobials may be considered on a patient-by-patient basis after careful consideration of clinical, microbiological, and logistical factors that may influence the probability of treatment success. This document reviews and evaluates currently available information on the post-dialytic administration of an expanded list of intravenous antimicrobials in the setting of thrice-weekly, high-flux IHD.

Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty

BACKGROUND

Staphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA.

METHODS

PubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies.

RESULTS

A total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous.

CONCLUSION

Preoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.

Staphylococcus aureus colonization increases the risk of bacteremia in hemodialysis patients: a molecular epidemiology approach with time-dependent analysis

BACKGROUND

Bacteremia is the second cause of death in hemodialysis patients and colonization may be a risk factor. We analyzed the association between Staphylococcus aureus or multidrug-resistant Gram-negative bacteria colonization and bacteremia in hemodialysis patients.

METHODS

A prospective cohort study was conducted. Colonization status was determined at baseline, 2, and 6 months later. The time-to-first-bacteremia was analyzed using the baseline status and time-dependent nature of colonization. The recurrence of bacteremia given colonization status was evaluated using a Poisson regression model. The genetic relatedness between isolates that colonized and caused bacteremia were established by molecular typing methods.

RESULTS

Seventy-one patients developed bacteremia over the course of follow-up, with the majority of cases being caused by S aureus (n = 28; 39.4%) and only three caused by multidrug-resistant Gram-negative bacteria. S aureus colonization was associated with an increased risk of bacteremia in time-dependent analysis (HR:4.64; 95%CI: 1.72-12.53) and with recurrence of infection in Poisson model (IRR:5.90, 95%CI: 2.29-15.16). Molecular methods revealed that 77.8% of patients with S aureus bacteremia were colonized with the same strain that caused the infection.

CONCLUSIONS

S aureus is a cause of endogenous infection in hemodialysis patients. Colonization is associated with both time-to-first-bacteremia and the recurrence of infection. The prompt identification of colonized patients and the evaluation of decolonization protocols are needed.

Decolonization of Staphylococcus aureus

Staphylococcus aureus infections are associated with increased morbidity, mortality, hospital stay, and health care costs. S aureus colonization has been shown to increase risk for invasive and noninvasive infections. Decolonization of S aureus has been evaluated in multiple patient settings as a possible strategy to decrease the risk of S aureus transmission and infection. In this article, we review the recent literature on S aureus decolonization in surgical patients, patients with recurrent skin and soft tissue infections, critically ill patients, hospitalized non-critically ill patients, dialysis patients, and nursing home residents to inform clinical practice.

Prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) Carrier in Hemodialysis Patients at Dr. Soetomo Academic General Hospital

Chronic kidney disease (CKD) is now a global epidemic, and the prevalence is increasing worldwide. Hemodialysis    is one of the ways to treat by kidney function replacement. Infection is the number two cause of death in patients with hemodialysis (HD). Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of bacteriemia in patients with dialysis. The epidemiological data of MRSA carriers in CKD in Indonesia are still scarce. This study was to determine the prevalence of MRSA carriers in patients at The Kidney and Hypertension Outpatient-clinic and Hemodialysis Installation at Dr. Soetomo Academic General Hospital, Surabaya Indonesia. The study design was descriptive-analytic with a cross- sectional study design. Sampling was collected consecutively. Data on the general characteristics of the research subjects will be analyzed using a Chi-Squared test. There were 150 CKD stage five patients included in this study, the number  of patients has MRSA carrier were 6 (4%), among them, subjects underwent HD MRSA carrier were 2 subjects(2.7%), while for non-HD patients with MRSA were 4 subjects (5.3 %). There were no significant differences in MRSA carriers between HD and non HD groups (p=0.404). Comorbid factors that accompany MRSA carriers are diabetes mellitus, hypertension, kidney stones, gout, and systemic lupus erythematosus (SLE).  This study found, there were no significant differences in the incidence of MRSA carriers in stage five CKD non HD or HD groups. MRSA colonization exists in stage five CKD sufferers, so awareness of MRSA colonization

Presence of egc-positive major clones ST 45, 30 and 22 among methicillin-resistant and methicillin-susceptible oral Staphylococcus aureus strains

The oral cavity may comprise a significant reservoir for Staphylococcus aureus but the data on molecular epidemiology and clonal distribution of oral strains are really scarce. This study aimed to evaluate the clonal relatedness in S. aureus isolated from oral cavity and their relationship with carriage of virulence genes, and antimicrobial resistance profiles. A total of 139 oral S. aureus isolates were obtained from 2327 analysed oral samples of dental patients. Antimicrobial susceptibility testing was performed. Isolates were characterized using protein A gene (spa) typing, spa-CC clonal complexes, toxin genes and SCCmec typing for MRSA. High resistance rates for penicillin, tetracycline and gentamicin were detected, respectively 58.3%, 42.4%, and 35.2%. Twelve (8.6%) S. aureus isolates were identified as MRSA. All of MRSA isolates were mecA-positive and mecC-negative. SCCmec IV was the most common type (66.7%), which was typical for community-acquired MRSA (CA-MRSA). Overall, the enterotoxin gene cluster (egc) was the most frequent detected virulence factor (44.9%), both in MSSA and MRSA isolates. Presence of genes encoding for the enterotoxins (sea, seb, sec, seh, sek), exfoliative toxin A (eta), and toxic shock syndrome toxin-1 (tst) was also observed. Strains carrying lukS-PV/lukF-PV genes belonged to SCCmecV- spa type t437. The most prevalent spa types were t091, t015, t084, t002, t571, and t026 among all 57 identified. Spa types, including 3 new ones, grouped in 6 different spa-CC clonal complexes, with four major dominated; CC45, CC30, CC5, and CC15. This study demonstrated that both methicillin-susceptible and methicillin-resistant major European clones of S. aureus could be isolated from the oral cavity of dental patients, with the emergence of PVL-positive CA-MRSA strains. The oral cavity should be considered as a possible source of toxigenic egc-positive S. aureus strains, in terms of potential risk of cross-infection and dissemination to other body sites.

Post-antibiotic era in hemodialysis? Two case reports of simultaneous colonization and bacteremia by multidrug-resistant bacteria

The emergence of resistance mechanisms not only limits the therapeutic options for common bacterial infections but also worsens the prognosis in patients who have conditions that increase the risk of bacterial infections. Thus, the effectiveness of important medical advances that seek to improve the quality of life of patients with chronic diseases is threatened. We report the simultaneous colonization and bacteremia by multidrug-resistant bacteria in two hemodialysis patients. The first patient was colonized by carbapenem- and colistin-resistant Klebsiella pneumoniae, carbapenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA). The patient had a bacteremia by MRSA, and molecular typing methods confirmed the colonizing isolate was the same strain that caused infection. The second case is of a patient colonized by extended-spectrum beta-lactamases (ESBL)-producing Escherichia coli and carbapenem-resistant Pseudomonas aeruginosa. During the follow-up period, the patient presented three episodes of bacteremia, one of these caused by ESBL-producing E. coli. Molecular methods confirmed colonization by the same clone of ESBL-producing E. coli at two time points, but with a different genetic pattern to the strain isolated from the blood culture. Colonization by multidrug-resistant bacteria allows not only the spread of these microorganisms, but also increases the subsequent risk of infections with limited treatments options. In addition to infection control measures, it is important to establish policies for the prudent use of antibiotics in dialysis units.

Restoring glucose uptake rescues neutrophil dysfunction and protects against systemic fungal infection in mouse models of kidney disease

Disseminated candidiasis caused by the fungus Candida albicans is a major clinical problem in individuals with kidney disease and accompanying uremia; disseminated candidiasis fatality is twice as common in patients with uremia as those with normal kidney function. Many antifungal drugs are nephrotoxic, making treatment of these patients particularly challenging. The underlying basis for this impaired capacity to control infections in uremic individuals is poorly understood. Here, we show in multiple models that uremic mice exhibit an increased susceptibility to systemic fungal infection. Uremia inhibits Glut1-mediated uptake of glucose in neutrophils by causing aberrant activation of GSK3β, resulting in reduced ROS generation and hence impaired killing of C. albicans in mice. Consequently, pharmacological inhibition of GSK3β restored glucose uptake and rescued ROS production and candidacidal function of neutrophils in uremic mice. Similarly, neutrophils isolated from patients with kidney disease and undergoing hemodialysis showed similar defect in the fungal killing activity, a phenotype rescued in the presence of a GSK3β inhibitor. These findings reveal a mechanism of neutrophil dysfunction during uremia and suggest a potentially translatable therapeutic avenue for treatment of disseminated candidiasis.

Spa gene-based molecular typing of nasal methicillin-susceptible staphylococcus aureus from patients and health-care workers in a dialysis center in southeast Iran

Staphylococcus aureus is an important infectious agent in hemodialysis patients. This study was conducted to determine the frequency of S. aureus nasal carriage in hemodialysis patients (HD) and health-care workers (HCW) at the main dialysis center of Bam city, located in southeast of Iran. In this cross-sectional study, a total of 52 nasal swabs were obtained from health-care workers and hemodialysis patients to detect methicillin-sensitive S. aureus (MSSA) isolates. The resistance to different antibacterial agents was determined by disk diffusion method. Also, Panton-Valentine Leukocidin (PVL) - encoding gene as well as Staphylococcal protein A (spa) type were determined. The nasal carriage rate of S. aureus was found to be 24.4% and 18.8% in patients on hemodialysis and health-care workers, respectively. Among identified isolates, no methicillin-resistant S. aureus (MRSA) was found. Only two MSSA isolates (16.7%) were resistant to trimethoprim/sulfamethoxazole. One isolate (8.6%) was positive for pvl gene. Moreover, 8 spa types were found. According to BURP analysis, six out of the 12 S. aureus isolates (50%) belonged to the same clone, indicating a prevalence of a major clone among MSSA in carriage, including patients and HCW. Mupirocin is still the appropriate drug for reducing nasal colonization in our setting. Accumulation of isolates from patients and staff in one spa clonal complex is alarming for the necessity of more serious infection control in this center. Therefore, it is necessary to screen patients and health-care workers as a health priority, in order to prevent cross transmission.

The prevalence and molecular mechanisms of mupirocin resistance in Staphylococcus aureus isolates from a Hospital in Cape Town, South Africa

Background

Antimicrobial resistance is an increasingly serious problem in public health globally. Monitoring resistance levels within healthcare and community settings is critical to combat its ongoing increase. This study aimed to describe the rates and molecular mechanisms of mupirocin resistance in clinical Staphylococcus aureus isolates from Tygerberg Hospital, and to describe its association with strain types.

Methods

We retrospectively selected 212 S. aureus isolates which were identified from blood samples and pus swabs during the years 2009–2011 and 2015–2017. The isolates were identified using conventional microbiological methods and genotyping was done using spa typing. Cefoxitin (30 μg) disc diffusion and the two disc strategy (5 μg and 200 μg) were used to determine susceptibility to methicillin and mupirocin, respectively. Isolates with high-level resistance were screened for the plasmid mediated genes mupA and mupB by PCR, and sequencing of the ileS gene was done for all isolates exhibiting low-level resistance to describe the mutations associated with this phenotype. Chi-square test was used to assess the associations between mupirocin resistance and S. aureus genotypes.

Results

Of 212 S. aureus isolates, 12% (n = 25) were resistant to mupirocin, and 44% (n = 93) were methicillin resistant. Strain typing identified 73 spa types with spa t045 being the most predominant constituting 11% of the isolates. High-level mupirocin resistance was observed in 2% (n = 5), and low-level resistance in 9% (n = 20) of the isolates. The prevalence of high-level mupirocin resistance amongst MRSA and MSSA was 4 and 1% respectively, while the prevalence of low-level mupirocin resistance was significantly higher in MRSA (18%) compared to MSSA (3%), (p = 0.032). mupA was the only resistance determinant for high-level resistance, and the IleS mutation V588F was identified in 95% of the isolates which showed low-level resistance. A significant association was observed between spa type t032 and high-level mupirocin resistance, and types t037 and t012 and low-level resistance (p <  0.0001).

Conclusion

The study reported higher rates of low-level mupirocin resistance compared to high-level resistance, and in our setting, mupirocin resistance was driven by certain genotypes. Our study advocates for the continuous screening for mupirocin resistance in S. aureus in clinical settings to better guide treatment and prescribing practices.

Surveillance of common infections in the early period after renal transplantation in a national center: 2014-2017

BACKGROUND

Infection prevention and timely and effective treatment are among the major aims of care in kidney transplant recipients. Pre-transplant vaccination and pre-transplant viral screening have been extensively studied and are now considered standard practice. Early post-operative infection surveillance is mandatory in other vulnerable cohorts, but has not been extensively studied in this population. We hypothesized that surveillance of the most common bacterial infection types in the post-transplant setting would be beneficial and identify key areas for improvement.

METHODS

All adult kidney transplant recipients whose surgeries were performed in the Irish national kidney transplant unit over a 1-year period had prospective early post-transplant (first 30 days) infection surveillance in 2014 for surgical site infection, urinary tract infection, and secondary bloodstream infections (Group T0). Several key changes were implemented following scrutiny of infection patterns and clinical practice. Subsequently, infection surveillance was undertaken for 2016 and 2017 (Group T1) to assess the impact of these changes.

RESULTS

Between 2014 and 2017, the number of kidney transplants increased by 32%. The following aspects of clinical practice were the focus of change following analysis of Group T0 data: timing of surgical antimicrobial prophylaxis (SAP) administration, choice of SAP antimicrobial agent, and routine microbiological testing in the peri-operative period. Following implementation of these changes, the timing of SAP administration was greatly improved (45%-100% of cases appropriately timed). The infection rate decreased from 8.9% to 7.4% in 2016, with a further decrease to 4% in 2017 (OR 0.42 (95% CI: 0.16-1.10); P = .08). Compliance with pre-operative microbiological screening improved in Group T1.

CONCLUSIONS

Simple clinical practice changes, implemented upon analysis of common bacterial infection surveillance data in the first 30 days after kidney transplantation resulted in more effective SAP administration and improved compliance with routine microbiological testing in the peri-operative period. These interventions have potentially contributed to reduced early post-operative infection rates, despite increased transplant activity in the unit. Infection surveillance is an important and under-utilized way of reducing infections in this vulnerable patient cohort.

Comparison of the effect of antibiotic-lock and ethanol-lock methods on infection rate in children with hemodialysis catheter

BACKGROUND

Hemodialysis catheter-related infection has a high incidence and complications. Antibiotic-lock or ethanol-lock can be used to prevent such infections. The aim of this study was to compare the effectiveness of antibiotic-lock and ethanol-lock methods in children undergoing hemodialysis and to evaluate the optimality of these methods.

METHODS

In this cohort clinical study, 25 children with chronic renal failure with hemodialysis catheter referring to Imam-Hossein Hospital in Isfahan, Iran, in 2016-2017 were studied. During two 6-month course, their catheter was locked first with antibiotics for 6 months, and then with ethanol for 6 months. Side effects, para-clinical findings and infectious species were also studied and data were analyzed.

RESULTS

In the first 6 months, 44% of the subjects and in the second 6 months, 12% of the subjects had catheter infections. The rate of infection, redness and catheter site sensitivity at the second 6-month course was significantly lower compared to the first 6-month course (P<0.05).

CONCLUSION

Both Antibiotic-lock and ethanol-lock are useful and practical methods for controlling infection. However, according to the results of this study, the ethanol-lock method seems to be more effective than antibiotic-lock in controlling the infection in children with hemodialysis catheter.

Risk factors for multidrug-resistant organisms among deceased organ donors

Donor infection or colonization with a multidrug-resistant organism (MDRO) affects organ utilization and recipient antibiotic management. Approaches to identifying donors at risk of carrying MDROs are unknown. We sought to determine the risk factors for MDROs among transplant donors. A multicenter retrospective cohort study was conducted at four transplant centers between 2015 and 2016. All deceased donors who donated at least one organ were included. Cultures obtained during the donor's terminal hospitalization and organ procurement were evaluated. The primary outcome was isolation of an MDRO on culture. Multivariable Cox regression was used to determine risk factors associated with time to donor MDRO. Of 440 total donors, 64 (15%) donors grew an MDRO on culture. Predictors of an MDRO on donor culture included hepatitis C viremia (hazard ratio [HR] 4.09, 95% confidence interval [CI] 1.71-9.78, P = .002), need for dialysis (HR 4.59, 95% CI 1.09-19.21, P = .037), prior hematopoietic cell transplant (HR 7.57, 95% CI 1.03-55.75, P = .047), and exposure to antibiotics with a narrow gram-negative spectrum (HR 1.13, 95% CI 1.00-1.27, P = .045). This is the first study to determine risk factors for MDROs among deceased donors and will be important for risk stratifying potential donors and informing transplant recipient prophylaxis.

The prevalence of methicillin-resistant Staphylococcus aureus among diabetic patients: a meta-analysis

AIMS

Diabetic patients have multiple risk factors for colonisation with methicillin-resistant Staphylococcus aureus (MRSA), a nosocomial pathogen associated with significant morbidity and mortality. This meta-analysis was conducted to estimate the prevalence of MRSA among diabetic patients.

METHODS

The MEDLINE, Embase, BIOSIS, and Web of Science databases were searched for studies published up to May 2018 that reported primary data on the prevalence of MRSA in 10 or more diabetic patients. Two authors independently assessed study eligibility and extracted the data. The main outcomes were the pooled prevalence rates of MRSA colonisation and infection among diabetic populations.

RESULTS

Eligible data sets were divided into three groups containing data about the prevalence of MRSA colonisation or in diabetic foot or other infections. From 23 data sets, the prevalence of MRSA colonisation among 11577 diabetics was 9.20% (95% CI, 6.26-12.63%). Comparison of data from 14 studies that examined diabetic and non-diabetic patients found that diabetics had a 4.75% greater colonisation rate (P < 0.0001). From 41 data sets, the prevalence of MRSA in 10994 diabetic foot infection patients was 16.78% (95% CI, 13.21-20.68%). Among 2147 non-foot skin and soft-tissue infections, the MRSA prevalence rate was 18.03% (95% CI, 6.64-33.41).

CONCLUSIONS

The prevalence of MRSA colonisation among diabetic patients is often higher than among non-diabetics; this may make targeted screening attractive. In the UK, many diabetic patients may already be covered by the current screening policies. The prevalence and impact of MRSA among diabetic healthcare workers requires further research. The high prevalence of MRSA among diabetic foot infections may have implications for antimicrobial resistance, and should encourage strategies aimed at infection prevention or alternative therapies.

Antimicrobial resistance in nephrology

The prevalence of antimicrobial resistance among many common bacterial pathogens is increasing. The emergence and global dissemination of these antibiotic-resistant bacteria (ARB) is fuelled by antibiotic selection pressure, inter-organism transmission of resistance determinants, suboptimal infection prevention practices and increasing ease and frequency of international travel, among other factors. Patients with chronic kidney disease, particularly those with end-stage renal disease who require dialysis and/or kidney transplantation, have some of the highest rates of colonization and infection with ARB worldwide. These ARB include methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp. and several multidrug-resistant Gram-negative organisms. Antimicrobial resistance limits treatment options and increases the risk of infection-related morbidity and mortality. Several new antibiotic agents with activity against some of the most common ARB have been developed, but resistance to these agents is already emerging and highlights the dire need for new treatment options as well as consistent implementation and improvement of basic infection prevention practices. Clinicians involved in the care of patients with renal disease must be familiar with the local epidemiology of ARB, remain vigilant for the emergence of novel resistance patterns and adhere strictly to practices proven to prevent transmission of ARB and other pathogens.

Staphylococcus aureus colonization in hemodialysis patients: a prospective 25 months observational study

Background

Dialysis patients are frequently exposed to Staphylococcus aureus due to stays in dialysis centers, hospitals or rest homes. The hemodialysis vascular access is a potential entry site for S. aureus, in particular when using a central venous catheter (CVC) which increases the risk of sepsis compared to arteriovenous (AV) fistula. We prospectively followed a cohort of 86 hemodialysis patients from an outpatient dialysis center over 25 months analyzing S. aureus carrier status, S. aureus infection rates and mortality.

Methods

Demographic data and patients´ medical histories were collected and followed from all hemodialysis patients. Blood samples, nasal swabs and swabs from the hemodialysis vascular access site were taken every six months for a period of 25 months and tested for S. aureus. Strains were cultured and further characterized by spa PCR and microarray-based genotyping. Resulting data were compared with those from the general population.

Results

In cross-sectional analyses, an average of 40% of hemodialysis patients were S. aureus carriers compared to 27% in the general population. Longitudinally, a total of 65% were S. aureus carriers: 16% were persistent carriers, 43% were intermittently colonized. The most common S. aureus lineage in the dialysis patient cohort was the clonal complex (CC) 8 and the spa type t008, while in the general population, the clonal complex CC30 dominates. During the study period, we observed six S. aureus-associated blood stream infections with one S. aureus attributable death. S. aureus carriers with an AV fistula were more densely colonized in the nasal mucosa compared to patients with a CVC. Overall mortality was lower for hemodialysis patients with a positive S. aureus carrier status compared to non-carriers (hazard ratio of 0.19).

Conclusions

Compared to the general population, hemodialysis patients were more frequently colonized with S. aureus and displayed both different S. aureus colonization densities as well as lineages, possibly explained by more frequent exposure to health care environments. The lower overall mortality in carriers compared to non-carriers is intriguing and will be investigated in detail in the future.

Trial registration

ISRCTN 14385893, 2. October 2018, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1332-z) contains supplementary material, which is available to authorized users.

The global and regional prevalence, burden, and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV-infected people: A systematic review and meta-analysis

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is among the most important opportunistic pathogens in HIV+ patients, resulting in considerable morbidity and mortality.

METHODS

The MEDLINE, Scopus, Web of Science, and EMBASE databases were comprehensively searched for studies that investigated the prevalence of MRSA colonization in HIV+ patients. We used a random effects model to calculate pooled prevalence estimates with 95% confidence intervals (CI) and analyzed data based on World Health Organization regions.

RESULTS

Among 9,772 records identified, 69 were included in the meta-analysis, comprising 30,050 HIV+ patients from 21 countries. We estimated the pooled worldwide prevalence of MRSA in people living with HIV to be 7% (95% CI 5%-9%, 1,623/30,050), with the highest prevalence in Southeast Asia (16%, 95% CI 9%-24%) and the region of the Americas (10%; 95% CI 7%-13%) and lowest prevalence in the European region (1%; 95% CI 0%-1%). Globally, we estimated approximately 2,659,000 (95% CI 1,835,000-3,303,000) HIV+ patients with colonized MRSA. Potential risk factors for MRSA colonization in HIV+ patients included previous MRSA infection (OR, 7.5; 95% CI, 3.91-14.37), hospitalization in the past year (OR, 1.87; 95% CI 1.11-3.16), and use of antibiotics (OR, 2.52; 95% CI 1.39-4.58).

CONCLUSIONS

Our findings emphasize the importance of routine screening for MRSA among all HIV+ patients throughout the world, especially in regions that have a high burden of disease.

Prevention and Treatment of Multidrug-Resistant Organisms in End-Stage Renal Disease

Chronic kidney disease patients are at high risk for infections because of multidrug-resistant organisms. Infections are the second most common cause of death in patients with ESRD. Patients with ESRD are prone to infections given alterations in immunity, increased rates of colonization with multidrug-resistant organisms, increased hospitalizations, and interactions with health care systems. Infections range from urinary tract infections, pneumonia, skin and soft tissue infections, central line-associated bloodstream infections to sepsis. A coordinated collaborative effort using a multipronged approach must be stressed to reduce the burden of infections. Preventive measures such as hand hygiene, antibiotic stewardship, immunizations, and minimizing central venous catheters are critical to curtail infections with multidrug-resistant organisms. Empirical and targeted treatment for multidrug-resistant organisms may require collaboration with infectious disease providers to improve outcomes in these serious infections. It is imperative to address multidrug-resistant organisms in ESRD patients at this juncture to improve medical outcomes now and for the future.

The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities

BACKGROUND

Antimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%-35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed.

OBJECTIVE

To quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.Study design and settingAn interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period.

RESULTS

Implementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met.

CONCLUSIONS

Within 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.

Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model

BACKGROUND AND OBJECTIVES

Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources.

RESULTS

On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs.

CONCLUSIONS

The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.

Association of Kidney Function with Infections by Multidrug-Resistant Organisms: An Electronic Medical Record Analysis

Antibiotic resistance is a major global health threat. High prevalences of colonization and infection with multi-drug resistance organisms (MDROs) have been reported in patients undergoing dialysis. It is unknown if this finding extends to patients with mild and moderate/severe kidney disease. An observational study included all adult incident patients hospitalized with a discharge diagnosis of infection in four hospitals from Guangzhou, China. Inclusion criteria: Serum creatinine measurement at admission together with microbial culture confirmed infections. Exclusion criterion: Undergoing renal replacement therapy. Four categories of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rate (eGFR) were compared: eGFR ≥ 105, 60–104 (reference), 30–59, and <30 ml/min/1.73 m². The odds ratio of MDROs, defined as specific pathogens (Staphylococcus aureus, Enterococcus spp., Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter spp.) resistant to three or more antibiotic classes, were calculated using a multivariable logistic regression model across eGFR strata. Of 94,445 total microbial culture records, 7,288 first positive cultures matched to infection diagnosis were selected. Among them, 5,028 (68.9%) were potential MDROs. The odds of infections by MDROs was 19% and 41% higher in those with eGFR between 30–59 ml/min/1.73 m² (Adjusted odds ratio, AOR): 1.19, 95% CI:1.02–1.38, P = 0.022) and eGFR < 30 ml/min/1.73 m² (AOR: 1.41, 95% CI:1.12–1.78, P = 0.004), respectively. Patients with impaired renal function have a higher risk of infections by MDROs. Kidney dysfunction at admission may be an indicator for need of closer attention to microbial culture results requiring subsequent change of antibiotics.