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Granata G, Petersen E, Capone A, Donati D, Andriolo B, Gross M, Cicalini S, Petrosillo N. The impact of armed conflict on the development and global spread of antibiotic resistance: a systematic review. Clin Microbiol Infect 2024:S1198-743X(24)00160-5. [PMID: 38556213 DOI: 10.1016/j.cmi.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Scant data are available on the link between armed conflicts and the development and spread of antimicrobial resistance. OBJECTIVES We performed a systematic review with the aim to summarize the available data on the prevalence and features of antibiotic resistance and the causes of antibiotic resistance development during armed conflicts in the 21st century. METHODS Data sources: PubMed and SCOPUS databases were searched from 1 January 2000 to 30 November 2023. STUDY ELIGIBILITY CRITERIA Original articles reporting data on armed conflicts and antimicrobial resistance were included in this systematic review. No attempt was made to obtain information from unpublished studies. No language restriction was applied. Methods of data synthesis: Both quantitative and qualitative information were summarized by means of textual descriptions. PARTICIPANTS Patients or soldiers deployed in armed conflict zones. TESTS culture-dependent antibiotic sensitivity testing or molecular detection of the genetic determinants of antibiotic resistance after a confirmed diagnosis of bacterial infection. Assessment of risk of bias: To evaluate the quality of the included studies, we adapted the tool recommended by the Joanna Briggs Institute. RESULTS Thirty-four studies were identified, published between November 2004 and November 2023. The quality of included studies was high and medium in 47% and 53% of the studies, respectively. The included studies reported high infection and colonization rates of multidrug-resistant bacteria. Studies performed during the Eastern Ukraine conflict reported high rates of New Delhi metallo-β-lactamase producers. DISCUSSION Our findings confirm that wars lead to a large pool of multidrug-resistant infections that could potentially spread. Infection control in healthcare facilities in conflict zones and proper antimicrobial stewardship are crucial.
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Affiliation(s)
- Guido Granata
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy.
| | - Eskild Petersen
- PandemiX Center of Excellence, Roskilde University, Roskilde, Denmark; European Society for Clinical Microbiology and Infectious Diseases Emerging Infections Subcommittee. European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland
| | - Alessandro Capone
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Daniele Donati
- Infection Prevention & Control/Infectious Disease Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Benedetta Andriolo
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Maya Gross
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Stefania Cicalini
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Nicola Petrosillo
- Infection Prevention & Control/Infectious Disease Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy; European Society for Clinical Microbiology and Infectious Diseases International Affairs SubCommittee. European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland
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Fischer M, Nonnenmacher L, Reichert JC, Bohnert JA, Idelevich EA, Doğan E, Becker K, Wassilew GI. Case Report: Hip arthroplasty after fracture-related joint infection caused by extensively drug-resistant Klebsiella pneumoniae. Front Surg 2024; 11:1363298. [PMID: 38476757 PMCID: PMC10927804 DOI: 10.3389/fsurg.2024.1363298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
This case-report focuses on a 23-year-old soldier suffering from a fracture-related hip joint infection (FRI) due to extensively drug-resistant Klebsiella pneumoniae and S. epidermidis. The patient underwent multiple septic revision surgeries including the removal of remaining shrapnel accompanied by last-resort antimicrobial therapy with cefiderocol and colistin. Additionally, the surgeries included repeated tissue sampling for microbiological and histopathological analysis. An antibiotic-loaded cemented filler containing cefiderocol was used to improve local antimicrobial therapy. The biopsies prior to and during hip replacement surgery confirmed successful microbe eradication. Hip arthroplasty restored hip joint function and significantly improved patient's quality of life. The utilization of a trabecular metal shell and a meta-diaphyseally anchored cementless hip stem ensured secure implant fixation and early patient mobilisation. An adjusted biofilm active oral antimicrobial therapy after arthroplasty intervention was continued to prevent early periprosthetic joint infection. This case emphasizes the difficulties of managing FRI and multidrug-resistant pathogens. It contributes valuable insight into navigating complex orthopedic cases while ensuring successful hip arthroplasty outcomes. In conclusion, early interdisciplinary collaboration, appropriate antimicrobial therapy along with tailored surgical interventions are crucial for managing such complex cases successfully.
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Affiliation(s)
- Maximilian Fischer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Lars Nonnenmacher
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Johannes C. Reichert
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jürgen A. Bohnert
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Evgeny A. Idelevich
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Eyüp Doğan
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Karsten Becker
- Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Georgi I. Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
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Pallett SJC, Boyd SE, O'Shea MK, Martin J, Jenkins DR, Hutley EJ. The contribution of human conflict to the development of antimicrobial resistance. Commun Med (Lond) 2023; 3:153. [PMID: 37880348 PMCID: PMC10600243 DOI: 10.1038/s43856-023-00386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023] Open
Abstract
Pallet et al. discuss the impact of human conflict on development of antimicrobial resistance. They overview approaches to limit the spread of antimicrobial resistance, using the ongoing conflict in Ukraine as an example of the challenges and opportunities.
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Affiliation(s)
- Scott J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK.
| | - Sara E Boyd
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Matthew K O'Shea
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Jessica Martin
- Department of Clinical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - David R Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK
| | - Emma J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
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Boyd SE, Holmes A, Peck R, Livermore DM, Hope W. OXA-48-Like β-Lactamases: Global Epidemiology, Treatment Options, and Development Pipeline. Antimicrob Agents Chemother 2022; 66:e0021622. [PMID: 35856662 DOI: 10.1128/aac.00216-22] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Modern medicine is threatened by the rising tide of antimicrobial resistance, especially among Gram-negative bacteria, where resistance to β-lactams is most often mediated by β-lactamases. The penicillin and cephalosporin ascendancies were, in their turn, ended by the proliferation of TEM penicillinases and CTX-M extended-spectrum β-lactamases. These class A β-lactamases have long been considered the most important. For carbapenems, however, the threat is increasingly from the insidious rise of a class D carbapenemase, OXA-48, and its close relatives. Over the past 20 years, OXA-48 and "OXA-48-like" enzymes have proliferated to become the most prevalent enterobacterial carbapenemases across much of Europe, Northern Africa, and the Middle East. OXA-48-like enzymes are notoriously difficult to detect because they often cause only low-level in vitro resistance to carbapenems, meaning that the true burden is likely underestimated. Despite this, they are associated with carbapenem treatment failures. A highly conserved incompatibility complex IncL plasmid scaffold often carries blaOXA-48 and may carry other antimicrobial resistance genes, leaving limited treatment options. High conjugation efficiency means that this plasmid is sometimes carried by multiple Enterobacterales in a single patient. Producers evade most β-lactam-β-lactamase inhibitor combinations, though promising agents have recently been licensed, notably ceftazidime-avibactam and cefiderocol. The molecular machinery enabling global spread, current treatment options, and the development pipeline of potential new therapies for Enterobacterales that produce OXA-48-like β-lactamases form the focus of this review.
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Beyene AM, Gezachew M, Mengesha D, Yousef A, Gelaw B. Prevalence and drug resistance patterns of Gram-negative enteric bacterial pathogens from diarrheic patients in Ethiopia: A systematic review and meta-analysis. PLoS One 2022; 17:e0265271. [PMID: 35294487 PMCID: PMC8926281 DOI: 10.1371/journal.pone.0265271] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Diarrhoea is the leading cause of morbidity and mortality in the world particularly in developing countries and among vulnerable groups of the population. Gram-negative enteric bacterial pathogens (GNEBPs) are a group of organisms that reside mainly in the intestine and induce diarrhoea. Antimicrobial agents are usually the part of their treatment regimen. The therapeutic effect of antimicrobials is hindered by the emergence and spread of drug-resistant strains. The information regarding the prevalence and antimicrobial resistance patterns of GNEBPs in Ethiopia is limited and found in a scattered form. Objectives This study was designed to determine the pooled prevalence and drug resistance patterns of GNEBPs by meta-analysis of data from diarrhoeic patients in Ethiopia. Method A comprehensive literature search was conducted through internet searches using Google Scholar, PubMed, Science Direct, HINARI databases, and reference lists of previous studies. Published articles were included in the study based on priorly set inclusion and exclusion criteria. Results were presented in the forest plot, tables, and figures with a 95% confidence interval (CI). The inconsistency index (I2) test statistics was used to assess heterogeneity across studies. The pooled prevalence estimate of GNEBPs and their drug resistance patterns were computed by a random-effects model. Software for Statistics and Data Science (STATA) version 14 statistical software was used for the analysis. Result After removing those articles which did not fulfil the inclusion criteria, 43 studies were included in the analysis. Studies were conducted in 8 regions of the country and most of the published articles were from the Amhara region (30.23%) followed by Oromia (18.60%) and Southern Nations, Nationalities, and Peoples’ region (SNNP) (18.60%). The pooled prevalence of GNEBPs was 15.81% (CI = 13.33–18.29). The funnel plot indicated the presence of publication bias. The pooled prevalence of GNEBPs in Addis Ababa, Amhara, SNNP, and Oromia regions were 20.08, 16.67, 12.12, and 11.61%, respectively. The pooled prevalence was 14.91, 18.03, and 13.46% among studies conducted from 2006–2010, 2011–2015, and 2016–2021, respectively and it was the highest (20.35%) in children having age less than or equal to 15 years. The pooled prevalence of Escherichia coli, Campylobacter spp., Shigella spp., and Salmonella enterica were 19.79, 10.76, 6.24, and 5.06%, respectively. Large proportions (60–90%) of the isolates were resistant to ampicillin, amoxicillin, tetracycline, and trimethoprim-sulphamethoxazole. The pooled prevalence of multidrug resistance (MDR) was 70.56% (CI = 64.56–76.77%) and MDR in Campylobacter spp., Shigella spp., E. coli, and S. enterica. were 80.78, 79.08, 78.20, and 59.46%, respectively. Conclusion The pooled estimate showed a high burden of GNEBPs infections and a high proportion of drug resistance characters to commonly used antimicrobial agents in Ethiopia. Therefore, performing drug susceptibility tests, establishing an antimicrobial surveillance system and confirmation by molecular techniques are needed.
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Affiliation(s)
- Achenef Melaku Beyene
- Department of Medical Microbiology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- * E-mail: ,
| | - Mucheye Gezachew
- Department of Medical Microbiology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Desalegn Mengesha
- Global One Health Initiative, East African Regional Office, Addis Ababa, Ethiopia
| | - Ahmed Yousef
- Department of Food Science and Technology, Ohio State University, Ohio, Columbus, United States of America
| | - Baye Gelaw
- Department of Medical Microbiology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Dootz F, von Stackelberg OM, Abaya J, Jacobi C, Mohs C, Craemer EM, Rangger C, Meyding-Lamadé U, Lamadé EK. Better be prepared: the spectrum of neuropsychiatric impairment among Libyan war victims transferred to Germany for trauma rehabilitation. Neurol Res Pract 2021; 3:36. [PMID: 34218812 PMCID: PMC8256548 DOI: 10.1186/s42466-021-00134-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
Background The current Libyan civil war has originated many casualties, imposing medical challenges. War injuries are complex, requiring specialized knowledge and interdisciplinary assessment for adequate patient and intercultural management. Methods This retrospective study analyzed records of 78 Libyan patients admitted from July 2016 to November 2017 to neurological and trauma surgical departments of Krankenhaus Nordwest, Frankfurt, Germany. Issues of system preparation of the hospital, demographics, injury patterns and therapies were analyzed. The chi-squared test was used to analyze differences in injury patterns in explosion and gunshot injuries. Results Seventy-seven of seventy-eight patients were male (mean age 30.6 years). The patients received primary and secondary treatment in Tunisia (n = 39), Libya (n = 36) and Turkey (n = 23). Forty-eight patients had gunshot injuries, 37 explosion injuries, 11 both. Preparation for management of injuries included hygienic and isolation protocols, organization of interpreters and intercultural training. Patients presented with a broad variety of neurological, psychiatric and trauma surgical injuries. Fifty-six patients had sensory, 47 motor deficits. Nine reported headache, 5 vertigo, 13 visual impairment, 28 psychiatric symptoms. Eighteen patients had central nervous damage, 50 peripheral nervous damage. Central nervous damage was significantly more common in gunshot than explosion injuries (p = 0.015). Peripheral nervous damage was more common in explosion than gunshot injuries (p < 0.1). Fifty-one patients had polytrauma and 49 suffered from fractures. Therapy included surgical interventions (n = 56) and physiotherapy. Structured rehabilitation programs were often indicated. Conclusion Specialized knowledge about war injuries and their management including hospital preparation and planning regarding infrastructure may be required anytime. Injuries include a broad variety of neurological, psychiatric and trauma surgical injuries. Therefore, an interdisciplinary approach is crucial.
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Affiliation(s)
- Felix Dootz
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen am Rhein, Germany
| | | | - Joan Abaya
- Ludwig-Maximilians-Universität, Munich, Germany
| | - Christian Jacobi
- Department of Neurology, Krankenhaus Nordwest, Frankfurt/Main, Germany
| | - Christoph Mohs
- Department of Neurology, Krankenhaus Nordwest, Frankfurt/Main, Germany
| | - Eva Maria Craemer
- Department of Neurology, Krankenhaus Nordwest, Frankfurt/Main, Germany.,International Institute of Medicine and Telemedicine, Frankfurt/Main, Germany
| | - Christoph Rangger
- Orthopedics and Trauma Surgery, Optimum Orthopädie, Frankfurt/Main, Germany
| | - Uta Meyding-Lamadé
- Department of Neurology, Krankenhaus Nordwest, Frankfurt/Main, Germany.,International Institute of Medicine and Telemedicine, Frankfurt/Main, Germany
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Alemayehu T. Prevalence of multidrug-resistant bacteria in Ethiopia: a systematic review and meta-analysis. J Glob Antimicrob Resist 2021; 26:133-139. [PMID: 34129993 DOI: 10.1016/j.jgar.2021.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Multidrug-resistant (MDR) bacteria are a significant public-health threat worldwide, especially in low- and middle-income countries. Comprehensive data are important to understand the magnitude of multidrug resistance (MDR), however these are not available in Ethiopia. METHODS Five electronic databases and grey literature of Addis Ababa University Repository were searched for data regarding the prevalence of MDR bacteria in Ethiopia. OpenMetaAnalyst R1.3 was used for analysis using a random-effects model to determine the effect size. Heterogeneity among articles was checked using the inconsistency index (I2). Funnel plot was used to check for publication bias. The quality of each article was checked using the Newcastle-Ottawa checklist adapted for cross-sectional studies. RESULTS Through database searching, 2094 articles were identified, of which 37 fulfilled the study inclusion criteria. This review comprises 6856 bacteria, of which 4949 isolates were MDR. The overall pooled prevalence of MDR was 70.5% (95% CI 64.9-76.1%), with considerable heterogeneity (I2 = 97.48%, P < 0.001). Funnel plot revealed no publication bias. Sidama (81.7%) had the highest MDR and Tigray (51.1%) the lowest. The greatest source of MDR was from multiple sites of infection (MSI) (76.8%); the least was from bloodstream infections (62.9%). MDR was higher in studies conducted on hospital-acquired infections (72.1%) compared with both hospital- and community-acquired infections (69.8%). CONCLUSION Our study indicates a high prevalence of MDR in Ethiopia. Sidama region, MSI and hospital-acquired infections showed the highest MDR in subgroup analysis. Regional hospitals should implement infection prevention and proper use of antibiotics in the community.
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Affiliation(s)
- Tsegaye Alemayehu
- Hawassa University College of Medicine and Health Science, School of Medical Laboratory, P.O. Box. 1560, Hawassa, Ethiopia.
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da Silva RB, Araujo RO, Salles MJ. Non-elective and revision arthroplasty are independently associated with hip and knee prosthetic joint infection caused by Acinetobacter baumannii: a Brazilian single center observational cohort study of 98 patients. BMC Musculoskelet Disord 2021; 22:511. [PMID: 34078354 PMCID: PMC8173725 DOI: 10.1186/s12891-021-04393-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/21/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) caused by Acinetobacter baumannii (Ab) has become a growing concern due to its overwhelming ability to express resistance to antibiotics and produce biofilm. AIM This study aimed to identify independent risk factors (RFs) associated with Ab-associated PJI and their role in the treatment outcome. METHODS This was a single-centre, retrospective cohort study of PJI patients diagnosed between January 2014 and July 2018. A PJI diagnosis was made based upon the MSIS 2018 criteria. To estimate RFs associated with Ab-associated PJI, multivariate analyses with a level of significance of p < 0.05 were performed. To evaluate treatment failure, Kaplan-Meier analysis and log-rank test were performed. RESULTS Overall, 98 PJI cases were assessed, including 33 with Ab-associated PJI and 65 with PJI involving other microorganisms (non-Ab-associated PJI). Independent RFs associated with Ab-associated PJI were revision arthroplasty [odds ratio (OR) = 3.01; 95% confidence interval (CI) = 1.15-7.90; p = 0.025] and nonelective arthroplasty (OR = 2.65; 95% CI = 1.01-7.01; p = 0.049). Ab-associated PJI was also more likely than non-Ab-associated PJI to be classified as a chronic late infection (OR = 5.81; 95% CI = 2.1-16.07; p = 0.001). Ab-associated PJI was not associated with treatment failure (p = 0.557). CONCLUSIONS Late chronic infections, surgical revision and nonelective arthroplasty are well-known predictors of PJI but were also independently associated with Ab-associated PJI. Infections caused by Ab and surgical treatment with debridement, antibiotics and implant retention were not associated with PJI treatment failure. TRIAL REGISTRATION Study data supporting our results were registered with the Brazilian Registry of Clinical Trials ( https://www.ensaiosclinicos.gov.br/rg/RBR-6ft5yb/ ), an open-access virtual platform for the registration of studies on humans performed in Brazil. Registration no. RBR-6ft5yb .
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Affiliation(s)
| | - Rodrigo Otavio Araujo
- Department of Orthopedics Hospital São Francisco de Assis, Belo Horizonte, MG, Brazil
| | - Mauro José Salles
- Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil. .,Departamento de medicina, Universidade Federal de São Paulo- Escola Paulista de Medicina (UNIFESP-EPM), Laboratório LEMC, Disciplina de infectologia, São Paulo, SP, Brazil.
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Wareth G, Neubauer H. The Animal-foods-environment interface of Klebsiella pneumoniae in Germany: an observational study on pathogenicity, resistance development and the current situation. Vet Res 2021; 52:16. [PMID: 33557913 PMCID: PMC7871605 DOI: 10.1186/s13567-020-00875-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/03/2020] [Indexed: 12/17/2022] Open
Abstract
Klebsiella (K.) pneumoniae as a multi-drug resistant (MDR) pathogen is an emerging challenge for clinicians worldwide. Virulence factors are capsular antigens, adherence factors, the O-lipopolysaccharide, and siderophores promoting infectivity. Mechanisms of antimicrobial resistance are inactivation of compounds via enzymes, change of membrane permeability, and alteration of the target site of the antimicrobial compound. In addition to environmental resistance, K. pneumoniae can survive increasing concentrations of disinfectants, if exposed. This review describes the temporal and spatial distribution of K. pneumoniae in the past decades in Germany, with emphases on the development of resistance in the non-human columns of the One-Health concept. In general, K. pneumoniae is a neglected pathogen in veterinary and environmental health, and the risk of human infection concerning animal contact and food consumption is barely investigated. Few reports exist (n = 26) on antibiotic resistance of isolates from non-human origin. Multi-drug resistance and extended-spectrum β-lactamase (MDR-ESBL) strains also resistant to carbapenems and antibiotics of the ß-lactam group harbor blaCTX-M, blaOXA, blaTEM, blaSHV, blaCMY, and PMQR have been found in animals, foods, and the environment. Colistin resistant strains carrying the mcr-1 gene were detected in wastewater. The blaCTX-M-15 and blaOXA-48 genes are the most frequently identified AMR genes in isolates of humans and were also the most predominant ESBL-genes in samples collected from animal hosts. Several aspects of the molecular epidemiology and resistance development of K. pneumoniae in farm animal populations, wildlife, and foods need intensive research. Environmental health has to be integrated into national research plans, as a lack of data is apparent. Increasing awareness of the fact that non-human sources can act as a reservoir for this pathogen has to be raised.
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Affiliation(s)
- Gamal Wareth
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Street 96a, 07743, Jena, Germany. .,Faculty of Veterinary Medicine, Benha University, Moshtohor, Toukh, 13736, Egypt.
| | - Heinrich Neubauer
- Friedrich-Loeffler-Institut, Institute of Bacterial Infections and Zoonoses, Naumburger Street 96a, 07743, Jena, Germany
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Ehlkes L, Pfeifer Y, Werner G, Ignatius R, Vogt M, Eckmanns T, Zanger P, Walter J. No evidence of carbapenemase-producing Enterobacteriaceae in stool samples of 1,544 asylum seekers arriving in Rhineland-Palatinate, Germany, April 2016 to March, 2017. ACTA ACUST UNITED AC 2020; 24. [PMID: 30808444 PMCID: PMC6446954 DOI: 10.2807/1560-7917.es.2019.24.8.1800030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Since 2015, increased migration from Asia and Africa to Europe has raised public health concerns about potential importation of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), specifically those producing carbapenemases (C-PE), into European hospitals. Aims: To inform infection control practices about ESBL-PE prevalence in asylum seekers and to investigate whether C-PE prevalence exceeds that in the German population. Methods: Cross-sectional study from April 2016–March 2017. Routinely collected stool samples from asylum seekers were tested for antibiotic resistant Enterobacteriaceae. Country/region of origin and demographic characteristics were explored as risk factors for faecal colonisation. Results: Of 1,544 individuals, 294 tested positive for ESBL-PE colonisation (19.0%; 95% confidence intervals (CI): 17.0–21.0). Asylum seekers originating from Afghanistan/Pakistan/Iran had a prevalence of 29.3% (95% CI: 25.6–33.2), from Syria 20.4% (95% CI: 16.1–25.2) and from Eritrea/Somalia 11.9% (95% CI: 8.7–15.7). CTX-M-15 (79%) and CTX-M-27 (10%) were the most common ESBL determinants. Highest ESBL-PE prevalences were observed in boys under 10 years and women aged 20–39 years (interaction: p = 0.03). No individuals tested positive for C-PE. Faecal C-PE colonisation prevalence in asylum seekers was not statistically significantly different from prevalence reported in German communities. Conclusion: In absence of other risk factors, being a newly arrived asylum seeker from a region with increased faecal ESBL-PE colonisation prevalence is not an indicator for C-PE colonisation and thus not a reason for pre-emptive screening and isolation upon hospital admission.
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Affiliation(s)
- Lutz Ehlkes
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.,Postgraduate Training for Applied Epidemiology (PAE), Robert Koch Institute, Berlin, Germany.,Federal State Agency for Consumer & Health Protection Rhineland-Palatinate, Koblenz, Germany
| | - Yvonne Pfeifer
- Robert Koch Institute, Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany
| | - Guido Werner
- Robert Koch Institute, Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany
| | - Ralf Ignatius
- Institute of Microbiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.,MVZ Labor 28, Berlin, Germany
| | - Manfred Vogt
- Federal State Agency for Consumer & Health Protection Rhineland-Palatinate, Koblenz, Germany
| | - Tim Eckmanns
- Robert Koch Institute, Nosocomial Infections and Surveillance of Antibiotic Resistance, Berlin, Germany
| | - Philipp Zanger
- These two authors have contributed equally to this manuscript and share last authorship.,Department of Infectious Diseases, Medical Microbiology and Hygiene, University Hospitals, Heidelberg, Germany.,Heidelberg Institute of Global Health, Unit of Epidemiology and Biostatistics, University Hospitals, Heidelberg, Germany.,Federal State Agency for Consumer & Health Protection Rhineland-Palatinate, Koblenz, Germany
| | - Jan Walter
- These two authors have contributed equally to this manuscript and share last authorship.,Robert Koch Institute, Nosocomial Infections and Surveillance of Antibiotic Resistance, Berlin, Germany
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11
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Adams DJ, Susi A, Nylund CM. Clinical characteristics, risk factors, and outcomes of patients hospitalized in the US military health system with carbapenem-resistant Enterobacteriaceae infection. Am J Infect Control 2020; 48:644-649. [PMID: 31757476 DOI: 10.1016/j.ajic.2019.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND We aimed to characterize the epidemiology, identify risk factors, and measure outcomes of carbapenem-resistant Enterobacteriaceae (CRE) infections among hospitalized patients. METHODS We performed a retrospective study of hospitalized patients with CRE infection using records from the US military health system database. Cases included patients admitted for ≥2 days from 2008-2015, with a clinical culture growing any Enterobacteriaceae reported as resistant to a carbapenem. Multivariable logistic regression was used to identify comorbid conditions and procedures associated with CRE infection, and a high-dimensional propensity score was used for a case-mix adjusted evaluation of CRE-associated in-hospital mortality, length of stay, and hospitalization costs. RESULTS From 1,162,686 hospitalized patients, we identified 143 with CRE infection over the 7-year study period. Conditions associated with CRE infection included manipulation of the gastrointestinal tract, musculoskeletal trauma, orthopedic procedures, septicemia, and both recent and remote exposure to broad-spectrum β-lactam antibiotics. Patients hospitalized with CRE infection had significantly higher hospitalization costs (attributable difference, $206,664; P < .001), longer hospital stays (attributable difference, 28.8 days; P < .001), and increased odds of in-hospital mortality (adjusted odds ratio, 3.34; 95% confidence interval, 1.82-6.12). CONCLUSIONS CRE are a significant threat to hospitalized patients. Our study quantifies the health care burden associated with CRE infection in the inpatient setting and highlights the importance of initiatives aimed at curbing the spread of these costly infections.
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12
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Abstract
Background: The threat of antimicrobial resistance continues to grow worldwide, exacerbated by poor antibiotic stewardship practices, limited development of new antimicrobial agents, and increasing globalization. Methods: This review covers previously published studies examining how human movement contributes to the global spread of antimicrobial resistance, including between low- and middle-income and high-income countries. Results: The emergence of resistance in one country or part of the world can become a worldwide event quickly. Human movement, including travel, medical tourism, military service, and migration, results in the globalization of resistant bacterial strains. Conclusions: Increased surveillance, whole-genome sequencing, focused infection control, and effective stewardship practices are needed to maintain the efficacy of antibiotics.
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Affiliation(s)
- Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California-San Diego, San Diego, California, USA
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13
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Hofmann F, Heudorf U, Steul K, Wichelhaus TA, Besier S, Hogardt M, Hack D, Steinmann E, Kempf VAJ, Reinheimer C. Anamnestic risk factor evaluation of patients carrying carbapenem-resistant Enterobacterales and/or Acinetobacter baumannii - impact on infection control management at a German University Hospital. GMS Hyg Infect Control 2020; 15:Doc05. [PMID: 32547905 PMCID: PMC7273331 DOI: 10.3205/dgkh000340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background: Carbapenem-resistant Enterobacterales and Acinetobacterbaumannii are of major concern in terms of infection prevention and control. This study evaluated factors that may increase the frequency of Enterobacterales and A. baumannii with carbapenem resistance (CR) in patients admitted to a German University Hospital for implementation of optimized infection control management. Methods: A five-year-retrospective epidemiological cohort analysis was conducted on anamnestic risk factors for carrying Enterobacterales and/or A. baumannii with CR in patients who were first tested positive for these species at University Hospital Frankfurt (UHF) between January 2013 and June 2018. Results: 364 patients were tested positive for Enterobacterales and/or A. baumannii with CR, resulting in n=400 bacterial isolates in total, with Klebsiella pneumoniae being the most frequently detected species (n=146/400; 36.5%; 95% confidence interval: 31.8–41.4). In patients who were tested positive for Enterobacterales and/or A. baumannii with CR, any hospital stay within the previous 12 months was the most frequently reported common factor (n=275/364; 75.5%; 70.8–79.9). Conclusion: A hospital stay within the previous 12 months, including hospitals in Germany and abroad, is a frequent characteristic of patients who tested positive for Enterobacterales and/or A. baumannii with CR. Upon admission, any previous hospital stay of the given patient within the previous 12 months should be determined. Infection control strategies such as screening measures need to be adapted to these patient groups in hospital settings. In order to reflect the varying determinants in “nosocomial” cases in greater detail, the existing criteria used to characterize “nosocomial detection” of gram-negative bacteria with CR should be reviewed.
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Affiliation(s)
- Franziska Hofmann
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Ursel Heudorf
- Public Health Department of the City of Frankfurt/Main, Germany
| | - Katrin Steul
- Public Health Department of the City of Frankfurt/Main, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Silke Besier
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Daniel Hack
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Elvira Steinmann
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
| | - Claudia Reinheimer
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Germany.,University Center of Competence for Infection Control, State of Hesse, Germany
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14
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Wareth G, Brandt C, Sprague LD, Neubauer H, Pletz MW. Spatio-Temporal Distribution of Acinetobacter baumannii in Germany-A Comprehensive Systematic Review of Studies on Resistance Development in Humans (2000-2018). Microorganisms 2020; 8:E375. [PMID: 32155886 DOI: 10.3390/microorganisms8030375] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 12/16/2022] Open
Abstract
Acinetobacter (A.) baumannii has gained global notoriety as a significant nosocomial pathogen because it is frequently associated with multi-drug resistance and hospital-based outbreaks. There is a substantial difference in the incidence of A. baumannii infections between different countries and within Germany. However, its continuous spread within Germany is a matter of concern. A systematic literature search and analysis of the literature published between 2000 and 2018 on A. baumannii in humans was performed. Forty-four studies out of 216 articles met the criteria for inclusion, and were selected and reviewed. The number of published articles is increasing over time gradually. Case reports and outbreak investigations are representing the main body of publications. North Rhine-Westphalia, Hesse and Baden-Wuerttemberg were states with frequent reports. Hospitals in Cologne and Frankfurt were often mentioned as specialized institutions. Multiresistant strains carrying diverse resistance genes were isolated in 13 of the 16 German states. The oxacillinase blaOXA-23-like, intrinsic blaOXA-51-like, blaOXA-58 variant, blaNDM-1, blaGES-11, blaCTX-M and blaTEM are the most predominant resistance traits found in German A. baumannii isolates. Five clonal lineages IC-2, IC-7, IC-1, IC-4 and IC-6 and six sequence types ST22, ST53, ST195, ST218, ST944/ST78 and ST348/ST2 have been reported. Due to multidrug resistance, colistin, tigecycline, aminoglycosides, fosfomycin, ceftazidime/avibactam and ceftolozan/tazobactam were often reported to be the only effective antibiotics left to treat quadruple multi-resistant Gram-negative (4MRGN) A. baumannii. Dissemination and infection rates of A. baumannii are on the rise nationwide. Hence, several aspects of resistance development and pathogenesis are not fully understood yet. Increased awareness, extensive study of mechanisms of resistance and development of alternative strategies for treatment are required. One-Health genomic surveillance is needed to understand the dynamics of spread, to identify the main reservoirs and routes of transmission and to develop targeted intervention strategies.
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15
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Yassine I, Rafei R, Osman M, Mallat H, Dabboussi F, Hamze M. Plasmid-mediated quinolone resistance: Mechanisms, detection, and epidemiology in the Arab countries. Infect Genet Evol 2019; 76:104020. [PMID: 31493557 DOI: 10.1016/j.meegid.2019.104020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/24/2019] [Accepted: 08/28/2019] [Indexed: 01/19/2023]
Abstract
Quinolones are an important antimicrobial class used widely in the treatment of enterobacterial infections. Although there are multiple mechanisms of quinolone resistance, attention should be paid to plasmid-mediated genes due to their ability to facilitate the spread of quinolone resistance, the selection of mutants with a higher-level of quinolone resistance, and the promotion of treatment failure. Since their discovery in 1998, plasmid-mediated quinolone resistance (PMQR) mechanisms have been reported more frequently worldwide especially with the extensive use of quinolones in humans and animals. Nevertheless, data from the Arab countries are rare and often scattered. Understanding the prevalence and distribution of PMQR is essential to stop the irrational use of quinolone in these countries. This manuscript describes the quinolone resistance mechanisms and particularly PMQR among Enterobacteriaceae as well as their methods of detection. Then the available data on the epidemiology of PMQR in clinical and environmental isolates from the Arab countries are extensively reviewed along with the other associated resistance genes. These data shows a wide dissemination of PMQR genes among Enterobacteriaceae isolates from humans, animals, and environments in these countries with increasing rates over the years and a common association with other antibiotic resistance genes as blaCTX-M-15. The incontrovertible emergence of PMQR in the Arab countries highlights the pressing need for effective stewardship efforts to prevent the selection of a higher rate of quinolone resistance and to preserve these crucial antibiotics.
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Affiliation(s)
- Iman Yassine
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon.
| | - Rayane Rafei
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Marwan Osman
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Hassan Mallat
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon.
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16
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Frickmann H, Podbielski A, Kreikemeyer B. Resistant Gram-Negative Bacteria and Diagnostic Point-of-Care Options for the Field Setting during Military Operations. Biomed Res Int 2018; 2018:9395420. [PMID: 30009178 DOI: 10.1155/2018/9395420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/20/2018] [Indexed: 12/16/2022]
Abstract
The spread of multidrug-resistant bacteria in resource-poor settings affects the military medical service in case of deployments of soldiers to war and crisis zones. Patients with war injuries are prone to colonization or infection with multidrug-resistant bacteria. Resistant Gram-negative bacteria play a dominant role in military wound infections. Problematic hygiene conditions on deployment facilitate exposition of soldiers with subsequent colonization. Although colonizing strains are frequently cleared from their hosts after returning from deployment, transmission to close contacts of the soldiers in the home country cannot be excluded and therapeutic options are reduced if colonization progresses to invasive infection. Since sophisticated culture-based diagnostic approaches are typically not available in the field setting on deployment, molecular rapid diagnostic test systems are an option for transmission control if the locally prevalent molecular resistance mechanisms are known. Efforts for global resistance surveillance can contribute to better understanding of resistance distribution and spread at deployment sites. This review summarizes experience of the military medical services with multidrug resistance on deployment and with the influx of resistant strains to the home country and discusses potential use of available molecular rapid test systems as an option for the field setting.
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17
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Frickmann H, Köller T, Hagen RM, Ebert KP, Müller M, Wenzel W, Gatzer R, Schotte U, Binder A, Skusa R, Warnke P, Podbielski A, Rückert C, Kreikemeyer B. Molecular Epidemiology of Multidrug-Resistant Bacteria Isolated from Libyan and Syrian Patients with War Injuries in Two Bundeswehr Hospitals in Germany. Eur J Microbiol Immunol (Bp) 2018; 8:1-11. [PMID: 29760959 PMCID: PMC5944420 DOI: 10.1556/1886.2018.00002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/31/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction We assessed the molecular epidemiology of multidrug-resistant bacteria colonizing or infecting war-injured patients from Libya and Syria who were treated at the Bundeswehr hospitals Hamburg and Westerstede, Germany. Methods Enterobacteriaceae and Gram-negative rod-shaped nonfermentative bacteria with resistance against third-generation methoxyimino cephalosporins or carbapenems as well as methicillin-resistant Staphylococcus aureus (MRSA) from war-injured patients from Libya and Syria were assessed by molecular typing, i.e., spa typing for MRSA strains and rep-PCR and next-generation sequencing (NGS) for Gram-negative isolates. Results A total of 66 isolates were assessed – comprising 44 Enterobacteriaceae, 16 nonfermentative rod-shaped bacteria, and 6 MRSA from 22 patients – and 8 strains from an assessment of the patient environment comprising 5 Enterobacteriaceae and 3 nonfermentative rod-shaped bacteria. Although 24 out of 66 patient strains were isolated more than 3 days after hospital admission, molecular typing suggested only 7 likely transmission events in the hospitals. Identified clonal clusters primarily suggested transmission events in the country of origin or during the medical evacuation flights. Conclusions Nosocomial transmissions in hospital can be efficiently prevented by hygiene precautions in spite of heavy colonization. Transmission prior to hospital admission like on evacuation flights or in crises zones needs further assessment.
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Affiliation(s)
- Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Thomas Köller
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Ralf Matthias Hagen
- Department of Preventive Medicine, Bundeswehr Medical Academy, Munich, Germany
| | - Klaus-Peter Ebert
- Hygiene Department, Bundeswehr Hospital Westerstede, Westerstede, Germany
| | - Martin Müller
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Werner Wenzel
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Renate Gatzer
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Ulrich Schotte
- Laboratory Department II, Central Institute of the Bundeswehr Kiel, Kiel-Kronshagen, Germany
| | - Alfred Binder
- Laboratory Department II, Central Institute of the Bundeswehr Kiel, Kiel-Kronshagen, Germany
| | - Romy Skusa
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Philipp Warnke
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Christian Rückert
- Centrum for Biotechnology (CeBiTec), University Bielefeld, Bielefeld, Germany
| | - Bernd Kreikemeyer
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
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