Bacteriuria and asymptomatic infection in chronic patients with indwelling urinary catheter: The incidence of ESBL bacteria

Incidence of catheter-associated urinary tract infections by Gram-negative bacilli and their ESBL and carbapenemase production in specialized hospitals of Bahir Dar, northwest Ethiopia

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) due to multidrug-resistant Gram-negative bacilli (GNB) is a common concern globally. Investigating the incidence of CAUTI and associated antibiotic resistance has paramount importance from the health care associated infections perspective. This study therefore assessed the incidence of CAUTIs due to GNB and the production of extended-spectrum beta-lactamase (ESBL) and carbapenemase among inpatients in specialized hospitals of Northwest, Ethiopia.

METHODS

A total of 363 patients with indwelling urinary catheters who were admitted in the hospital for > 48 h were consecutively enrolled and followed from 3 to 18 days. Data were collected through interviewing and review of medical records. Patients who developed at least one of the following: fever (> 38 OC), suprapubic tenderness, or costovertebral angle pain, coupled with a GNB positive urine culture of ≥ 103 CFU/mL with no more than two bacterial species were defined as CAUTI. The ESBL and carbapenemase production were detected and identified by chromogenic medium. Logistic regression analysis was done to identify associated factors.

RESULTS

From 363 patients followed, the incidence rate of CAUTI was 27.8 per 1000 catheter days. Catheterization for ≥ 8 days (AOR = 10.6, 95%CI:1.8-62.1) and hospitalization for > 10 days (AOR = 8.1, 95%CI: 2.4-27.2) were the factors significantly associated with CAUTIs. E. coli (n = 18, 34.6%), Proteus species (n = 7, 13.5%), and P. aeruginosa (n = 6, 11.5%) were the most frequent GNB. Isolates revealed high rates of resistance to amoxicillin-clavulanic acid (100%), cefazolin (n = 51, 98%), ceftazidime (n = 47, 90%) and cefotaxime (n = 46, 88%). Most of the GNB isolates (86.5%) were multidrug-resistant. Overall, 19.2% and 5.8% of GNB isolates were ESBL and carbapenemase producers, respectively.

CONCLUSIONS

Incidence of CAUTI with Gram-negative bacilli is high. As most of the GNB isolates are MDR and showed a super high rate of resistance to amoxicillin-clavulanic and third-generation cephalosporins, empirical treatment with these substances is virtually ineffective in patients with suspected GNB infection in Ethiopia. The expression of ESBL and carbapenemase among GNB isolates is also a concern. Therefore, improved infection prevention and control measures, careful use of catheters and third generation of cephalosporins are needed to improve patient outcomes and reduce the burden of CAUTIs and the spreading of antimicrobial resistance.

Epidemiology of pathogens and antimicrobial resistance of nosocomial urinary tract infections in patients with spinal cord injuries in China: A systematic review and meta-analysis

CONTEXT

Despite a high urinary tract infection (UTI) rate in spinal cord injured patents in China, there is limited evidence on the epidemiological character of that.

OBJECTIVE

The purpose of our article was to characterize the distribution of pathogens of UTI patients with spinal cord injuries (SCI) and the resistance profile of pathogens.

METHODS

A literature search of six electronic databases was carried out to identify the incidence, pathogen distribution, and drug resistance of UTI after SCI based on our inclusion and exclusion criteria. Meta-analysis was carried out using R 4.0.2 software; a subgroup analysis was performed by the year 2012.

RESULTS

We screened 1110 eligible studies, 33 were included in our final review. A total of 7271 bacterial species were included in our studies; 6092 were gram-negative (81.13% [76.83-85.11]) and 1003 were gram-positive (14.89% [11.70-18.38]). Before 2012, E. coli (45.43%) was the predominant isolated pathogen, followed by Klebsiella (7.49%) and Enterococcus (6.01%). After 2012, E. coli (50.23%) was the main pathogen, followed by Klebsiella (12.47%) and Proteus (6.88%). E. coli was more likely to be resistant to Levofloxacin, Amikacin, sulfonamides, 4th-generation cephalosporins and Nitrofurantoin before 2012 (81.8% vs. 62.9%, 32.0% vs. 7.6%, 81.3% vs. 61.6%, 81.8% vs. 24.1%, 33.5% vs. 5.1%), whereas E. coli was more frequently resistant to Inhibitor-resistant β-lactamas after 2012 (56.3% vs. 34.0%). K. pneumoniae was more likely to be resistant to Aztreonam, Amikacin before 2012 (80.0% vs. 39.8%, 48.1% vs. 19.0%). P. aeruginosa presented a high resistance to Levofloxacin, Inhibitor-resistant β-lactamas after 2012 (61.8% vs. 35.6%, 59.1% vs. 5.7%).

CONCLUSIONS

UTI in patients with SCI in China were mainly caused by gram-negative bacteria. We observed a remarkable modification in resistance profiles of pathogen distribution before 2012 and after 2012, which suggests reasonable control of the use of antibiotics has a positive effectiveness on resistance profiles.

Total Knee Arthroplasty in Patients with Spinal Cord Injury: Impact on Medical Complications, Hospital Costs and Length of Stay

INTRODUCTION

Patients with spinal cord injury (SCI) with degenerative joint disease of the knee may require total knee arthroplasty (TKA). This study examines the demographic and immediate postoperative outcomes of patients with SCI who undergo TKA.

METHODS

Admissions data for TKA and SCI were analyzed from the National Inpatient Sample database using International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. An extensive array of preoperative and postoperative variables was compared among SCI TKA patients and non-SCI TKA patients. An unmatched and matched analysis using a 1:1 propensity match algorithm was conducted to compare the two groups.

RESULTS

Patients with SCI tend to be younger and have a 7.518 times greater risk of acute renal failure, 2.3 times greater risk of blood loss, and higher risk of local complications, including periprosthetic fracture and prosthetic infection. The average length of stay in the SCI cohort was 2.12 times greater, with a 1.58 times higher mean total incurred charge than the non-SCI group.

CONCLUSION

SCI is associated with an increased risk of acute renal failure, blood loss anemia, periprosthetic fractures and infections, a longer length of stay, and greater incurred charges in TKA patients.

STUDY DESIGN

Retrospective study.

Is early time to positivity of blood culture associated with clinical prognosis in patients with Klebsiella pneumoniae bloodstream infection?

The association between time to positivity (TTP) of blood culture and the clinical prognosis of patients with Klebsiella pneumoniae bloodstream infection (BSI) remains unclear. A retrospective study of 148 inpatients with BSI caused by K. pneumoniae was performed at Shanghai Tongji Hospital, China, from October 2016-2020. The total in-hospital fatality rate was 32%. The median TTP was 11.0 (7.7-16.1) h and the optimal cutoff for prediction of in-hospital mortality was 9.4 h according to the ROC curve. Early TTP (<9.4 h) was a risk factor for in-hospital mortality by univariate analysis (OR = 2.5, 95% CI 1.2-5.0, P = 0.01), but not by multivariate analysis (OR = 2.7, 95% CI 1.0-7.4, P = 0.06). Old age, serum creatinine, white blood cells, and C-reactive protein values were risk factors for in-hospital mortality by multivariate analysis. Early TTP was not a risk factor for septic shock (OR = 1.8, 95% CI 0.6-5.1, P = 0.27) or ICU admission (OR = 1.0, 95% CI 1.0-1.0, P = 0.32). In conclusion, the in-hospital fatality rate of patients with K. pneumoniae BSI was relatively high and associated with an early TTP of blood cultures. However, no increased risk of mortality, septic shock or ICU admission was evident in early TTP patients.

Resistance to Some New Drugs and Prevalence of ESBL- and MBL-Producing Enterobacteriaceae Uropathogens Isolated from Diabetic Patients

Diabetes is a leading non-communicable disease and a risk factor for relapsing infections. The current study was aimed at investigating the prevalence and antibiotic susceptibility of carbapenem-resistant (CR) uropathogens of the family Enterobacteriaceae in diabetic patients. The data of 910 bacterial isolates was collected from diagnostic laboratories during January 2018 to December 2018. The bacterial isolates were identified using traditional methods including colonial characteristics, biochemical tests, and API (20E). Antimicrobial susceptibility and phenotypic characterization of ESBL, MBLs, and KPC was determined by utilizing CLSI recommended methods. The phenotypically positive isolates were further analyzed for resistance-encoding genes by manual PCR and Check-MDR CT103XL microarray. Susceptibility to colistin and cefiderocol was tested in accordance with CLSI guidelines. The data revealed that most of the patients were suffering from type 2 diabetes for a duration of more than a year and with uncontrolled blood sugar levels. Escherichia coli and Klebsiella pneumoniae were the most frequently encountered pathogens, followed by Enterobacter cloacae and Proteus mirabilis. More than 50% of the isolates showed resistance to 22 antibiotics, with the highest resistance (>80%) against tetracycline, ampicillin, and cefazolin. The uropathogens showed less resistance to non-β-lactam antibiotics, including amikacin, fosfomycin, and nitrofurantoin. In the phenotypic assays, 495 (54.3%) isolates were found to be ESBL producers, while ESBL-TEM and -PER were the most prevalent ESBL types. The resistance to carbapenems was slightly less (250; 27.5%) than ESBL producers, yet more common amongst E. coli isolates. MBL production was a common feature in carbapenem-resistant isolates (71.2%); genotypic characterization also validated this trend. The isolates were found to be sensitive against the new drugs, cefiderocol and eravacycline. with 7−28% resistance, except for P. mirabilis which had 100% resistance against eravacycline. This study concludes that a few types of ESBL and carbapenemases are common in the uropathogens isolated from the diabetic patients, and antibiotic stewardship programs need to be revisited, particularly to cure UTIs in diabetic patients.

Biocompatibility and biocidal effects of modified polylactide composites

Polylactide (PLA) materials treated with antimicrobial fillers represent a suitable alternative to the production of medical devices. Their advantage is that they can prevent the growth of microorganisms and the formation of microbial biofilms on the surface and around composites. The work is focused on the evaluation of biocompatibility and biocide effect of PLA composite films filled with vermiculite and graphene oxide modified with silver (Ag⁺ and Ag nanoparticles), hexadecylpyridinium (HDP) and hexadecyltrimethylammonium (HDTMA) cations and their degradation leachates monitored at 1-3-6-month intervals. The antimicrobial effect of the leachates was detected by microdilution methods on gram-negative (Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis), gram-positive (Staphylococcus aureus, Streptococcus salivarius) bacteria and yeast (Candida albicans). The biocidal effect of composites on biofilm formation on the surface of composites was monitored by Christensen method and autoaggregation and motility tests. The biocompatibility of the composite and the leachates was assessed by 3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide (MTT) cytotoxicity assay. The evaluation of the antimicrobial effect of the leachates demonstrated that leachates of PLA composite filled with graphene oxide and Ag⁺ showed a stronger antimicrobial effect than leachates of PLA composite filled with vermiculite and Ag⁺ and Ag nanoparticles. The leachates of PLA composites containing vermiculite with HDP and HDTMA cations had a higher antimicrobial effect on G⁺ bacteria and yeast than G^- bacteria. Bacterial growth, biofilm formation, autoaggregation and motility of the tested bacteria were most inhibited by the composite with vermiculite and Ag⁺ and Ag nanoparticles. Even after a 6-month degradation of this composite, bacterial growth and biofilm formation continued to be strongly inhibited up to 42 and 91%, respectively. The cytotoxic effect was proved only in the leachate of the composite with vermiculite containing HDP after 6 months of its degradation. Tests evaluating the biocompatibility of materials have shown that the vermiculite is the most preferred carrier and can be used in the future to bind other compounds. The study confirmed that PLA composite filled with vermiculite and Ag⁺ and Ag nanoparticles was the most stable and effective composite with the best biocompatible and biocidal properties.

Recent Advances in Antimicrobial Coatings and Material Modification Strategies for Preventing Urinary Catheter-Associated Complications

In recent years, we have witnessed prominent improvements in urinary catheter coatings to tackle the commonly occurring catheter-associated urinary tract infection (CAUTI) in catheterized patients. CAUTIs are claimed to be one of the most frequent nosocomial infections that can lead to various complications, from catheter encrustation to severe septicaemia and pyelonephritis. Besides general prevention hygienic strategies, antimicrobial-coated urinary catheters show great potential in the prevention of urinary catheter-associated complications. The aim of this review is to present and evaluate recent updates on the development of antimicrobial urinary catheters in the context of the aetiology of urinary malfunction. Subsequently, we shed some light on future perspectives of utilizing 3D printing and the surrounding regulatory directions.

Measurement of Plasma Galectin-3 Concentrations in Patients with Catheter Infections: A Post Hoc Retrospective Cohort Study

Catheter-related infections (CRIs) include catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs), and they are associated with high morbidity, mortality, and healthcare costs. The diagnosis of a CRI is made difficult by its non-specific symptoms. We aimed to investigate the factors influencing the plasma concentration of galectin-3 in catheter-bearing patients and to explore its potential usefulness as an index for CRIs. Circulating the concentrations of galectin-3, we measured the chemokine (C-C) motif ligand 2, procalcitonin, and C-reactive protein in 110 patients with a central catheter, in 165 patients with a urinary catheter, and in 72 control subjects. Catheter-bearing patients had higher concentrations (p < 0.001) of galectin-3 than the control group [central catheter: 19.1 (14.0−23.4) µg/L; urinary catheter: 17.1 (12.7−25.4) µg/L; control group: 6.1 (5.0−8.7) µg/L]. We identified chronic kidney disease as an independent determinant of galectin-3 concentrations in patients with a central catheter, and serum creatinine, cardiovascular disease, and number of days that the catheter was indwelling were identified as determinants in urinary catheter patients. We found that measuring galectin-3 concentrations in urinary catheter patients with a CRI was more accurate for diagnosis than the other parameters. We conclude that the measurement of galectin-3 concentration may be useful for assessing the inflammatory status of catheter-bearing patients and may contribute to the diagnosis of CRIs in those with a urinary catheter.

Highly hydrophobic polytetrafluoroethylene particle immobilization via polydopamine anchor layer on nitric oxide releasing polymer for biomedical applications

Biomedical surface-associated infections and thrombus formation are two major clinical issues that challenge patient safety and patient the fate of a medical device in the body . Single platform multifunctional surfaces are critical to address both these indwelling medical device-related problems. In this work, bio-inspired approaches are employed to fabricate a polymer composite with a versatile surface that can reduce bacterial infections and platelet adhesion in vitro. In the first bio-inspired approach, the functionality of nitric oxide (NO) produced by endothelial cell lining of blood vessels is mimicked through incorporation of S-nitroso-N-acetylpenicillamine (SNAP) within a CarboSil-2080A™ (CarboSil) polymer composite matrix. The second approach involves utilizing mussel adhesive chemistry, via polydopamine (PDA) to immobilize polytetrafluoroethylene (PTFE) particles on the polymer composite surface. The PTFE coating facilitates a decrease in wettability by making the polymer composite surface highly hydrophobic (contact angle ca. 120°). The surface of the fabricated polymer composite , CarboSil SNAP-PTFE, had a cobblestone-like structured appearance as characterized through scanning electron microscopy (SEM). Water contact angle (WCA) and surface tension measurements indicated no significant coating losses after 24 h under physiological conditions. NO surface flux was measured and analyzed for 5 days using a chemiluminescence-based nitric oxide analyzer and was found to be within the physiological range. CarboSil SNAP-PTFE reduced adhered bacteria (99.3 ± 0.5% for Gram-positive S. aureus and 99.1 ± 0.4% for Gram-negative E. coli) in a 24 h in vitro study. SEM analysis showed the absence of biofilm formation on CarboSil SNAP-PTFE polymer composites, while present on CarboSil in 24 h exposure to S. aureus. Platelet adhesion was reduced by 83.3 ± 4.5%. Overall, the results of this study suggest that a combination of NO-releasing CarboSil with PTFE coating can drastically reduce infection and platelet adhesion.

Comprehensive study of antimicrobial susceptibility pattern and extended spectrum beta-lactamase (ESBL) prevalence in bacteria isolated from urine samples

Nowadays, increasing extended-spectrum β-lactamase (ESBL)-producing bacteria have become a global concern because of inducing resistance toward most of the antimicrobial classes and making the treatment difficult. In order to achieve an appropriate treatment option, identification of the prevalent species which generate ESBL as well as their antibiotic susceptibility pattern is essential worldwide. Hence, this study aimed to investigate the prevalence of ESBL-producing bacteria and assess their drug susceptibility in Fardis Town, Iran. A total of 21,604 urine samples collected from patients suspected to have urinary tract infection (UTI) were processed in the current study. The antimicrobial susceptibility of the isolates was tested by the disk diffusion method. The ESBL producing bacteria were determined by Double Disc Synergy Test (DDST) procedure. Bacterial growth was detected in 1408 (6.52%) cases. The most common bacterial strains causing UTI were found E. coli (72.16%), followed by K. pneumoniae (10.3%) and S. agalactiae (5.7%). Overall, 398 (28.26%) were ESBL producer. The highest ESBL production was observed in E. coli, followed by Klebsiella species. ESBL producers revealed a higher level of antibiotic resistance compared with non-ESBLs. In conclusion, ESBL production in uropathogens was relatively high. Carbapenems and Aminoglycosides were confirmed as the most effective treatment options for these bacteria.

Comprehensive study of antimicrobial susceptibility pattern and extended spectrum beta-lactamase (ESBL) prevalence in bacteria isolated from urine samples

Nowadays, increasing extended-spectrum β-lactamase (ESBL)-producing bacteria have become a global concern because of inducing resistance toward most of the antimicrobial classes and making the treatment difficult. In order to achieve an appropriate treatment option, identification of the prevalent species which generate ESBL as well as their antibiotic susceptibility pattern is essential worldwide. Hence, this study aimed to investigate the prevalence of ESBL-producing bacteria and assess their drug susceptibility in Fardis Town, Iran. A total of 21,604 urine samples collected from patients suspected to have urinary tract infection (UTI) were processed in the current study. The antimicrobial susceptibility of the isolates was tested by the disk diffusion method. The ESBL producing bacteria were determined by Double Disc Synergy Test (DDST) procedure. Bacterial growth was detected in 1408 (6.52%) cases. The most common bacterial strains causing UTI were found E. coli (72.16%), followed by K. pneumoniae (10.3%) and S. agalactiae (5.7%). Overall, 398 (28.26%) were ESBL producer. The highest ESBL production was observed in E. coli, followed by Klebsiella species. ESBL producers revealed a higher level of antibiotic resistance compared with non-ESBLs. In conclusion, ESBL production in uropathogens was relatively high. Carbapenems and Aminoglycosides were confirmed as the most effective treatment options for these bacteria.

In Situ Deposition of Green Silver Nanoparticles on Urinary Catheters under Photo-Irradiation for Antibacterial Properties

Urinary tract infections, especially catheter-associated urinary tract infections (CAUTIs), are the most common type of nosocomial infections. Patients with chronic indwelling urinary catheters have a higher risk of infection due to biofilm formation on the urinary catheter surface. Therefore, in this work, a novel, cost-effective antimicrobial urinary catheter was developed using green technology. Silver nanoparticles (AgNPs) synthesized from Mon Thong durian rind waste were used as an antimicrobial agent for the prevention of infection. Flavonoids, phenolic compounds, and glucose extracted from durian rind were used as a reducing agent to reduce the Ag+ dissolved in AgNO3 solution to form non-aggregated AgNPs under light irradiation. The AgNPs were simultaneously synthesized and coated on the inner and outer surfaces of silicone indwelling urinary catheters using the dip coating method. The results showed that the antimicrobial urinary catheter fabricated using a 0.3 mM AgNO3 concentration and 48 h coating time gave the highest antibacterial activity. The as-prepared spherical AgNPs with an average diameter of 9.1 ± 0.4 nm formed on catheter surfaces in a monolayer approximately 1.3 µm thick corresponding to a 0.712 mg/cm2 silver content. The AgNP layer was found to damage and almost completely inhibit the growth of Escherichia coli cells with antibacterial activity by 91%, equivalent to the commercial, high-price antimicrobial urinary catheter. The cumulative amount of silver released from the coated catheter through artificial urine over 10 days was about 0.040 µg/mL, which is less than the silver content that causes tissue and organ toxicity at 44 µg/mL. Thus, we concluded that the developed antimicrobial urinary catheter was useful in reducing the risk of infectious complications in patients with indwelling catheters.

Re-Potentiation of β-Lactam Antibiotic by Synergistic Combination with Biogenic Copper Oxide Nanocubes against Biofilm Forming Multidrug-Resistant Bacteria

Biofilm-associated tissue and device infection is a major threat to therapy. The present work aims to potentiate β-lactam antibiotics with biologically synthesized copper oxide nanoparticles. The synergistic combination of amoxyclav with copper oxide nanoparticles was investigated by checkerboard assay and time-kill assay against bacteria isolated from a burn wound and a urinary catheter. The control of biofilm formation and extracellular polymeric substance production by the synergistic combination was quantified in well plate assay. The effect of copper oxide nanoparticles on the viability of human dermal fibroblasts was evaluated. The minimum inhibitory concentration and minimum bactericidal concentration of amoxyclav were 70 μg/mL and 140 μg/mL, respectively, against Proteus mirabilis and 50 μg/mL and 100 μg/mL, respectively, against Staphylococcus aureus. The synergistic combination of amoxyclav with copper oxide nanoparticles reduced the minimum inhibitory concentration of amoxyclav by 16-fold against P. mirabilis and 32-fold against S. aureus. Above 17.5 μg/mL, amoxyclav exhibited additive activity with copper oxide nanoparticles against P. mirabilis. The time-kill assay showed the efficacy of the synergistic combination on the complete inhibition of P. mirabilis and S. aureus within 20 h and 24 h, respectively, whereas amoxyclav and copper oxide nanoparticles did not inhibit P. mirabilis and S. aureus until 48 h. The synergistic combination of amoxyclav with copper oxide nanoparticles significantly reduced the biofilm formed by P. mirabilis and S. aureus by 85% and 93%, respectively. The concentration of proteins, carbohydrates, and DNA in extracellular polymeric substances of the biofilm was significantly reduced by the synergistic combination of amoxyclav and copper oxide nanoparticles. The fibroblast cells cultured in the presence of copper oxide nanoparticles showed normal morphology with 99.47% viability. No cytopathic effect was observed. Thus, the study demonstrated the re-potentiation of amoxyclav by copper oxide nanoparticles.

Microbiology and Drug Resistance of Pathogens in Patients Hospitalized at the Nephrology Department in the South of Poland

A retrospective study was conducted among 498 patients with urinary tract infections (UTI) referred to our department from January 2013 to December 2015. This study was performed to evaluate the etiology of UTI and the antibiotic susceptibility profile of Escherichia coli (E. coli) as the main etiological factor in different age groups. Urine samples were examined using standard microbiological methods. Three hundred sixty-three samples (72.9%) were identified as E. coli, of which 29 (8.0%) can produce extended-spectrum β-lactamases (ESBL). E. coli was highly sensitive to imipenem (100.0%), gentamicin (91.0%), nitrofurantoin (89.4%), amikacin (88.2%), piperacillin/tazobactam (87.0%) and cephalosporins (79.7–89.5%). Low sensitivity was found in relation to fluoroquinolones (60.3–70.4%). E. coli was least sensitive to ampicillin (30.2%) and amoxicillin/clavulanic acid (49.9%). We observed a significant fall in susceptibility level to piperacillin/tazobactam (68.4% vs. 88.8%; p = 0.017), amikacin (61.1% vs. 90.7%; p = 0.001), gentamicin (70.0% vs. 93.2%; p = 0.002), cefalexin (41.2% vs. 83.3%; p < 0.001), cefotaxime (63.6% vs. 89.4%; p = 0.002), ceftazidime (61.9% vs. 85.6%; p = 0.008), cefepime (73.7% vs. 91.1%; p = 0.025), ciprofloxacin (54.1% vs. 72.2%; p = 0.024) and norfloxacin (40.5% vs. 62.5%; p = 0.011) among patients with catheter-associated UTI (CAUTI) compared to those with non-CAUTI. A similar susceptibility profile was observed between different age groups. In the longevity, E. coli showed a higher sensitivity to cephalosporins than in the young-old group. E. coli susceptibility to fluoroquinolones was low, which excludes them as a first-line drug in our department. Nitrofurantoin may be used as an alternative drug to carbapenems. Monitoring of susceptibility pattern is of great importance.