Correlation Between the Suitability of Empirical and Definitive Therapies According to Culture Results with the Clinical Outcomes of Patients with Bacteremia Due to Carbapenem- Resistant Acinetobacter baumannii (CRAB) at Dr. Soetomo Tertiary Referral Hospital

Carbapenem administration is an important therapy for nosocomial infections due to MDRO, especially Acinetobacter baumannii. The global increase in carbapenem-resistant A. baumannii (CRAB) that causes this pathogen has significantly threatened public health due to the lack of adequate treatment options due to the very few currently available antimicrobial agents that actively fight CRAB. Antimicrobial resistance is a major negative impact of inappropriate antimicrobial prescribing. Ineffective empiric treatment (initial antibiotic regimen not sensitive to identified pathogens based on in vitro sensitivity test results) is associated with a higher rate of deaths compared to effective empiric treatment. In this study, we analyzed the correlation between the suitability of empiric and definitive antibiotics and the clinical outcomes of patients with bacteremia due to CRAB treated in the inpatient ward of Dr. Soetomo Tertiary Referral Hospital, Surabaya. There were 227 isolates of bacteremia due to CRAB, consisting of 156 carbapenem-resistant A. baumanni and 71 carbapenem-sensitive A. baumannii. There were 88 isolates that met the inclusion and exclusion criteria, and all of them were resistant to ceftriaxone, cefepime, and ciprofloxacin. A total of 29.5% of the isolates were sensitive to cotrimoxazole, 3.4% of the isolates were sensitive to tigecycline, and 2.3% of the isolates were sensitive to amikacin, levofloxacin, and cefoperazone sulbactam. Adequate empirical antibiotics and definitive antibiotics (sensitive based on culture sensitivity test) amounted to 12.5% and 27.3%, respectively. There is no significant correlation between the suitability of empiric and definitive therapies with the patients' clinical outcomes (death and length of stay).Copyright © 2022 Phcogj.Com.

Impact of improving infection control and antibiotic stewardship practices on nosocomial infections and antimicrobial resistance in an oncology centre from India

Background: Improving basic infection control (IC) practices, diagnostics and anti-microbial stewardship (AMS) are key tools to handle antimicrobial resistance (AMR). Material(s) and Method(s): This is a retrospective study done over 6 years (2016-2021) in an oncology centre in North India with many on-going interventions to improve IC practices, diagnostics and AMS. This study looked into AMR patterns from clinical isolates, rates of hospital acquired infections (HAI) and clinical outcomes. Result(s): Over all, 98,915 samples were sent for culture from 158,191 admitted patients. Most commonly isolated organism was E. coli (n = 6951;30.1%) followed by Klebsiella pneumoniae (n = 5801;25.1%) and Pseudomonas aeroginosa (n = 3041;13.1%). VRE (Vancomycin resistant Enterococcus) rates fell down from 43.5% in Jan-June 2016 to 12.2% in July-Dec 2021, same was seen in CR (carbapenem resistant) Pseudomonas (23.0%-20.6%, CR Acinetobacter (66.6%-17.02%) and CR E. coli (21.6%-19.4%) over the same study period. Rate of isolation of Candida spp. from non-sterile sites also showed reduction (1.68 per 100 patients to 0.65 per 100 patients). Incidence of health care associated infections also fell from 2.3 to 1.19 per 1000 line days for CLABSI, 2.28 to 1.88 per 1000 catheter days for CAUTI. There was no change in overall mortality rates across the study period. Conclusion(s): This study emphasizes the point that improving compliance to standard IC recommendations and improving diagnostics can help in reducing the burden of antimicrobial resistance.Copyright © 2023 Indian Association of Medical Microbiologists

Antibiotic therapy of Acinetobacter baumannii bloodstream infection in COVID-19 patients

Secondary bacterial infection is one of the important risk factors for the development of severe course and death in COVID-19. The rational choice of antibacterial therapy is based on the data of microbiological monitoring of pathogens of healthcare-associated infections. The aim of the study is to determine the main options for antibiotic therapy of Acinetobacter baumannii bloodstream infection in COVID-19 patients. Material and methods. A retrospective, single-centre, uncontrolled study of the incidence of A. baumannii bacteremia in COVID-19 patients treated at the City Clinical Hospital No. 52 in Moscow from October 2020 to September 2021 was performed. For each strain of A. baumannii sensitivity to the main antibacterial agents was determined. Genetic determinants of antibiotic resistance were studied by real-time multiplex polymerase chain reaction. The main therapeutic options for A. baumannii bloodstream infection were analyzed. Results and discussion. Bloodstream infections were diagnosed in 4.7% of hospitalized patients with COVID-19 (758/16 047). Gram-negative bacteria were the causative agents of bloodstream infections in 76% of cases. A. baumannii were isolated from the blood of 143 patients (0.89%). Detection of the pathogen in the blood of COVID-19 patients was associated with severe and extremely severe course of the disease. Most of the strains (93%) were isolated in the intensive care unit. The A. baumannii strains studied were carbapenem-resistant (CRAb) and phenotypically belonged to the XDR class. According to a PCR study, A. baumannii strains were producers of oxacillinases OXA-23, OXA-40, and OXA-51. Conclusion. The circulation of A. baumannii CRAb in intensive care units makes empiric therapy based on carbapenems irrational and ineffective. For the etiotropic therapy of A. baumannii bloodstream infection it is recommended to use combined antibiotic therapy regimens with the inclusion of polymyxin B and sulbactam.Copyright © Eco-Vector, 2022.

Risk of Microbial Transmission in Reusing Gloves after Alcohol-Based Hand Hygiene

Intro: The need for re-use of gloves as an alternative to single use was raised in times of resource shortages because during the coronavirus disease 2019 pandemic, marked increase in healthcare associated infection was reported, which might owing to shortage of personal protective equipment. we aimed to evaluate the risk of microbial transmission by comparing residual microorganism after multiple patient contact according to with or without gloves in clinical practice. Method(s): Three researchers made rounds of patients while touching the same area successively followed by alcohol-based hand rub: one with bare hands, one with single gloves, and one with double gloves. Hand imprints were obtained before and after rounds, and cultured to count colony-forming units (CFU). The number of colonies was compared between groups in a semi-quantitative manner by hand area. Finding(s): Mean CFU counts after round were 10.06 for bare hands, 31.22 for single-gloved hands, and 49.67 for double-gloved hands (p=0.084). The most commonly identified microorganism after rounding was coagulase-negative Staphylococci (77.8%, 42/54), followed by Bacillus species (62.9%, 34/54). Carbapenem-resistant Acinetobacter baumannii was confirmed from a pair of double-gloved hand specimens after the rounds. That round included a patient with the same organism with the same antibiotic susceptibility results. More microorganisms were remained after alcohol-based hand rub on gloved hands than on bare hands. Conclusion(s): From our results, the possibility of microbial transmission seems more likely in gloved hands than in bare hands even after alcohol-based hand rub. Therefore, we do not recommend the re-use of gloves after alcohol-based hand hygiene.Copyright © 2023

Screening Strategies in Different Resource Settings

Health care-associated infections/ Hospital-acquired infections (HAIs) have a significant impact on patients' morbidity and mortality. The risk of HAIs in resource-limited settings (RLS) has been reported 2-20 times higher than that in developed countries. Moreover, multi-drug- resistant organisms (MDROs) have emerged and spread throughout the world. In addition, increases in HAIs were observed during the COVID-19 pandemic throughout the world.Thus, screening strategies/surveillance of MDROs were recommended as a core component of infection prevention and control (IPC) measures for the effective HAIs prevention. We review and summarize current critical knowledge on screening strategies in different resource settings, especially on guidelines for the prevention and control of carbapenem- resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) in health care facilities. The guidelines (especially WHO) were strongly recommended for surveillance of CRE-CRAB-CRPsA infections and surveillance cultures of asymptomatic CRE colonization. There were conditional recommended on surveillance cultures of the environment for CRE-CRAB-CRPsA colonization/contamination. The surveillance cultures (stool samples or rectal swabs) allowed the early introduction of IPC measures to prevent transmission to other patients and the hospital environment. Given the clinical importance of CRE-CRAB-CRPsA infections, regular ongoing active surveillance of infections were required in all microbiology laboratory settings. In addition, surveillance cultures for asymptomatic CRE colonization should also be performed, guided by local epidemiology and risk assessment. The surveillance cultures of asymptomatic CRE colonization should be considered for patients with previous CRE colonization and patients with a history of recent hospitalization in endemic CRE settings or contacted CRE colonized/ infected patients. In contrast, the evidence available on surveillance cultures for CRAB and CRPsA colonization in asymptomatic patients was not sufficiently relevant for the recommendation. Nowadays, the CRE surveillance strategies have been implemented in various methods from traditional culture- based methods to molecular assays. The limitation of microbiology laboratory capacity for MDROs in RLS was concerning. However, the surveillance data would help with appropriate IPC measure implementation and outbreak investigations. Thus, the proper screening strategies and strengthening microbiology laboratory capacity, especially in RLS are challenge for improving IPC measures and patient outcomes.Copyright © 2023

Epidemiological Features of Healthcare-associated Acinetobacter baumannii Infections in Taiwan During 2008 - 2019

Background: Acinetobacter baumannii can reside in humans without causing infection or symptoms but can opportunistically cause community and nosocomial infections. Few studies from Taiwan have used national-level data to investigate antibiotic resistance rates of A. baumannii infections in the intensive care units (ICUs) of medical centers. Aim(s): This study determined the number of infection sites of A. baumannii and the resistance rates of carbapenem-resistant A. baumannii (CRAB) infections in ICUs in Taiwan, and identified trends over time, variations of infection site, and factors associated with resistance. Method(s): This study used the database provided by Taiwan's Centers for Disease Control. Yearly, Taiwan Nosocomial Infections Surveillance System Surveys from 2008 to 2019 were analyzed, including data on the site of infection and resistance rates of A. baumannii and patient and hospital characteristics. Result(s): On average, 21 hospitals as medical center/year participated in the survey, and 6803 A. baumannii isolates were identified. All isolates were health care-related infections. The most frequent sites of infection were the urinary tract (50.6%), respiratory tract (19.6%), bloodstream (18.2%), surgical wounds (4.3%), and others (7.4%). Infection rates were the highest in the urinary tract in 2019 (63.6%;P < 0.001). On average, the rate of carbapenem resistance was 66.6% (95% confidence interval: 63.1-70.1) among ICU patients at medical centers. Considerable regional differences were observed, with the highest rates of resistance in the central regions. Higher resistance rates were observed between 2019 and 2020 COVID-19 pandemic (74.2%). Conclusion(s): This is the first report on the prevalence of health care-related A. baumannii infection in Taiwan in 2008-2019. Several invasive diseases, such as urinary tract infections, are associated with higher rates of carbapenem resistance. The resistance rate of CRAB in Taiwan is exceptionally high. The current big-data-derived findings may inform future surveillance and research efforts in Taiwan.Copyright © 2023 Wolters Kluwer Medknow Publications. All rights reserved.

An unusual presentation of malignant Invasive Mucinous Adenocarcinoma of Lung mimicking Pulmonary Renal syndrome

Background: A 54-year- old male presented to our centre with a chronic non-productive cough and breathlessness. Recent history of COVID treated and resolved few months back. He had a history of brain surgery performed five years back but details not known. Physical examination revealed no oedema and bilateral coarse creps with bronchiolar breathing. Laboratory findings indicated neutrophilic leucocytosis, elevated inflammatory markers, with elevated troponin I and D dimers. Urine analysis suggested microscopic haematuria with sediments. While 24 hour quantification revealed sub nephrotic proteinuria. As auto immune workup and vasculitis profile was negative and patient has not improved in spite of standard of therapy hence we went ahead with CT-Chest indicating ground-glass opacities in bilateral lung parenchyma and prominent interlobular/intralobular septal thickening. Then Bronchoscopy done which revealed the blood-stained secretions in the main stem bronchi and diffuse alveolar haemorrhage in bilateral bronchial segments indicating an inflammatory study, while tuberculosis diagnostic panel and infective bio fire panel in BAL was negative. Meanwhile, his repeat BAL culture suggested Carbapenem resistant Acinetobacter baumannii complex infection. As the patient did not respond to the standard of care for vasculitis. Probability considered was a small vessel vasculitis (namely Granulomatous polyangiitis) was considered due to lung manifestation involving upper respiratory tract with epistaxis, neutrophilic leucocytosis, elevated acute reactive protein, and renal manifestation including microscopic haematuria and proteinuria. However he responded poorly to conventional standard of treatment including pulse steroids and IVIG. Hence after MDT discussion we proceeded with lung biopsy which showed linear cores of lung tissue infiltrated by a malignant neoplasm and acinar pattern suggesting Invasive mucinous adenocarcinoma. Hence we went ahead with the biopsy diagnosis for the treatment plan. As he was to be started on chemotherapy, but he suddenly collapsed and went into hypotension, bradycardia, and cardiac arrest. In spite of high supports and post 4 cycles of CPR, was unable to revive and sadly succumbed to his illness. Discussion(s): In this rare case, the original diagnosis pointed to the pulmonary-renal syndrome, an autoimmune disease characterized by diffuse pulmonary haemorrhage and glomerulonephritis. However, negative autoimmune antibodies and vasculitis profile along with lung biopsy results indicated an unusual case of malignant lung adenocarcinoma presented with pulmonary renal syndrome. Conclusion(s): In cases suggesting pulmonary-renal syndromes, if autoimmune work up is negative and response is suboptimal relook the diagnosis.

Trends in the Rates of Multidrug-resistant Bacteria Commonly Associated with Healthcare in U.S. Acute Care Hospitals, 2019-June 2021

Background. Several studies demonstrated an increase in hospital-onset (HO) infections during the COVID-19 pandemic. We examined trends in the rates of multidrug-resistant (MDR) infections among acute care hospitals in the United States (U.S.) for bacteria commonly associated with healthcare: methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase production (ESBL), vancomycin resistant Enterococcus (VRE), MDR Pseudomonas aeruginosa, carbapenem resistant Enterobacteriaceae (CRE), and carbapenem-resistant Acinetobacter species (CRAB). Methods. We measured incidence of clinical cultures yielding the bacterial species of interest among hospitalized patients in a dynamic cohort of hospitals submitting data to the Premier Healthcare Database Special COVID-19 Release during 2019-June 2021. Community-onset (CO) cultures were obtained <= day 3 of hospitalization;HOwere obtained >= day 4. We determined monthly hospital-specific rates for each species. We used generalized estimating equations (GEE) multivariable negative binomial regression models adjusting for hospital characteristics to examine trends. Results. From 2019-June 2021, the overall number of hospitals contributing data was 318. Rates for each pathogen are shown in Figures 1 and 2. All pathogens' HO rates were significantly higher in 2021 compared with 2019. The rates of ESBL, VRE, and CRE were also significantly higher in 2021 when compared to 2020 (Table 1a). For CO rates, we found that MRSA rates decreased significantly during the study period, while ESBL, VRE, and CRE increased with varying degree of significance (Table 1b). Rates of CO MDR Pseudomonas and CO CRAB did not significantly change. Conclusion. Our study confirmed that the rates of several MDR infections increased during the COVID-19 pandemic through June 2021, especially HO infections. CO MRSA was the only pathogen with consistent and significant decline. As infections caused by MDR pathogens represent a serious threat to patient safety, further study of factors contributing to the emerging trends may inform prevention strategies during a pandemic. (Figure Presented).

An outbreak of carbapenem-resistant Acinetobacter baumannii in an isolation ward for COVID-19 and successful outbreak control with infection control measures

Background. The superinfection of multidrug-resistant bacteria is an important complication in critically ill COVID-19 patients. An outbreak of carbapenemresistant Acinetobacter baumannii (CRAB) occurred in an isolation ward for COVID-19. We performed an outbreak investigation, and successfully controlled the outbreak with the enhanced environmental cleaning and additional gowning and gloving. Methods. This study analyzed all COVID-19 patients with CRAB in any specimen, who admitted to an isolation ward for COVID-19 of a tertiary hospital in South Korea from October to November 2021. Results. During the outbreak period, a total of 23 patients with COVID-19 and CRAB were identified (Figure 1). Index case was 85-year old female patient who was referred from a long-term care facility. The mean age of cases was 72.9 and 14 (60.9%) patients were male. In most patients (91.3%), CRAB were identified in sputum culture, two were identified in blood culture at initial, and four patients were identified in sputum and blood culture at the same time. Most of the patients were applying high flow nasal cannula (26.1%) or mechanical ventilation (60.9%)(Table1). As shown in figure2, CRAB outbreak occurred mainly in the wards around the index case, and in particular, environmental culture was carried out in the area marked with a rectangle. CRAB was cultured on the floor, air inlet, air outlet, and window frame of the ward except for wards 3305 and 3319. Phenotypic antimicrobial resistance patterns of CRAB isolates from patients and environment were identical, and additional whole genome sequencing analyses are ongoing to find the clonality of isolates. We applied the infection control measures with the enhanced environmental cleaning using sodium hypochlorite(NaClO) 1000ppm and phenolic compounds more than twice a day, enhanced hand hygiene, and additional gowning and gloving over personal protective equipment (PPE) mandatory for COVID-19 on 29th October. No additional CRAB cases occurred since 2nd November 2021 for two weeks. Conclusion. Even when PPEs and precautions for COVID-19 are applied to isolation wards for COVID-19, it is helpful for preventing transmission of multidrug-resistant bacteria to apply additional contact precautions and environmental cleaning.

Combination Eravacycline Therapy for Carbapenem-Resistant Acinetobacter baumannii Pneumonia

Background. Acinetobacter baumannii typically causes infections in debilitated, hospitalized patients and is difficult to treat due to multiple virulence factors and the presence of intrinsic and acquired antibiotic resistance mechanisms leading to frequent isolation of multi-drug resistant (MDR) phenotypes. Due to problematic pharmacokinetics and/or dose-limiting toxicities of salvage agents, combination therapy with aminoglycosides, ampicillin/sulbactam, polymyxins, minocycline, or tigecycline, is often used. Eravacycline has demonstrated greater in-vitro potency against A. baumannii compared to other tetracycline derivatives making it potentially the more appealing option. However, its utility is hindered by a lack of data supporting pharmacodynamic targets and adequate dosing strategies for CRAB. The goal of this case series was to describe our experience with the use of combination eravacycline therapy for the treatment of CRAB pneumonia. Methods. This case series included all patients >= 18 years of age, diagnosed with SARS-CoV-2, >= 1 sputum culture positive for CRAB and a clinical diagnosis of new bacterial pneumonia, who received at least one dose of eravacycline between April 1st and October 1st, 2020. The primary outcome was clinical resolution of CRAB pneumonia. Secondary outcomes evaluated microbiological resolution, need for extended durations of therapy, and frequency of re-starting CRAB therapy within 48 hours of completion. Results. In total, 25 patients were included in this case series. The median duration of combination therapy was 10 days. Most patients (96%) received eravacycline + ampicillin/sulbactam, with 7 of those patients also receiving inhaled colistin (Table 2). In total, 17 (68%) patients achieved clinical resolution of CRAB pneumonia. Post-treatment sputum cultures were collected in 18 patients, of which 13 (72%) achieved microbiological resolution. One patient received > 14 days of therapy and no patients re-initiated therapy within 48 hours of eravacycline completion. Table 1: Baseline Characteristics Table 2: Study Outcomes Conclusion. In this small case series, eravacycline showed favorable clinical outcomes in patients with CRAB pneumonia. In light of limited treatment options, this agent can be considered for CRAB pneumonia salvage therapy.

Antibiotic-resistant gram-negative bacterial infections among persons with or without a prior positive test for SARS-CoV-2 in 10 U.S. sites, 2020

Background. The Centers for Disease Control and Prevention's Emerging Infections Program (EIP) conducts active laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE), extended spectrum beta-lactamase-producing Enterobacterales (ESBL-E), and carbapenem-resistant Acinetobacter baumannii (CRAB) in 10 U.S. sites. To describe the impact of the COVID-19 pandemic on the epidemiology of these antibiotic-resistant gram-negative bacteria (AR-GNB), we assessed characteristics of AR-GNB patients with and without a prior SARS-CoV-2 positive (SC2+) viral test. Methods. In 2020 among EIP catchment-area residents, an incident CRAB or CRE case was defined as the first isolation of A. baumannii complex, Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes, K. oxytoca, K. pneumonia, or K. variicola in a 30-day period resistant to >=1 carbapenem (excluding ertapenem for CRAB) from a normally sterile site or urine. An incident ESBL-E case was defined as the first isolation of E. coli, K. pneumonia, or K. oxytoca in a 30-day period resistant to any third-generation cephalosporin and non-resistant to all carbapenems from a normally sterile site or urine. Patient charts were reviewed. Results. Of 3904 AR-GNB cases with data available, 163 (4%) had a prior SC2+ test (85 ESBL-E, 70 CRE, and 8 CRAB). Median time from the most recent SC2+ test to AR-GNB culture date was 20 days (IQR 1-48 days). AR-GNB cases with a SC2+ test versus those without were more likely to be Black, non-Hispanic than another race/ ethnicity (31% vs 15%;P< 0.0001), aged >=65 years (62% vs 52%;P=0.0139), and to have prior healthcare exposures (63% vs 49%;P=0.0003) and indwelling devices (51% vs 28%;P< 0.0001). They were also more likely to have bacteremia (24% vs 11%;P< 0.0001), pneumonia (6% vs 1%;P< 0.0001) and be hospitalized around the time of their AR-GNB culture (67% vs 36%;P< 0.0001);median time from SC2 + test to hospital admission was 0.5 day (IQR 0-29.5 days). Conclusion. AR-GNB infections preceded by a SC2+ test were rare but more severe and associated with more healthcare risk factors. This underscores the need for continued infection prevention and control practices and monitoring of these infections during the COVID-19 pandemic.

Population-Based Co-infection of Carbapenem-Resistant Organisms and SARS-CoV-2 in Massachusetts

Background. Concerns about antibiotic resistance are exacerbated in COVID-19 patients due to frequent antibiotic use, increase in mechanical ventilation and reusable equipment, conservation of PPE, and strain on hospital staff. We described cases with co-infection of carbapenem-resistant organisms (CRO) and SARS-CoV-2 and compared rates in the Massachusetts population. Methods. All providers and hospitals are required to report CROs and SARS-CoV-2 to the Massachusetts Virtual Epidemiologic Network (MAVEN). We selected cases with both a positive SARS-CoV-2 test and a laboratory confirmed CRO from January through July 2020. We classified by which result occurred first and described demographic and clinical characteristics. We standardized the CRO case definition by excluding CR-Pseudomonas aeruginosa and calculated rates per 100,000 to assess the impact of SARS-CoV-2 on the population-based frequency of CROs. Analyses were conducted in SAS 9.4. Results. 28 confirmed cases of SARS-CoV-2 infection were also diagnosed with a CRO. They were an average age of 71.8, 60.7% male, 67.9% white, and 64.3% were in congregate care prior to their diagnoses. Mortality was 5/28 (17.9%). The 23 (82.1%) with a positive SARS-CoV-2 result first were all hospitalized at least once compared to 40% in the CRO first group (p=0.003). 11 (47.8%) of the SARS-CoV-2 first were already admitted when they tested CRO positive;7 (30.4%) were admitted for the CRO separately from COVID-19 treatment. None of the CRO first group were admitted for CRO infection. Average length of stay for the SARS-CoV-2 first group was higher than the CRO first group (62.3 days vs 11.0 days;p=0.049). Cases positive for CRO first were all infected with CR-Escherichia coli whereas those positive for SARS-CoV-2 first were infected with CRAB, CRPA, or a CRE (Klebsiella oxytoca or Klebsiella pneumoniae) (p< 0.0001). The rate of CRO/COVID coinfection was 0.203 per 100,000 population;the rates for January through July of CRO alone were 2.5 per 100,000 in 2020 and 2.4 per 100,000 in 2019. Conclusion. Characteristics of individuals co-infected with CRO and SARSCoV-2 differed by which diagnosis was made first;however, the SARS-CoV-2 pandemic did not impact the CRO population rate during the time frame studied.

Impact of SARS-CoV-2 Epidemic on Antimicrobial Resistance: A Literature Review.

Antimicrobial resistance is an urgent threat to public health and global development; in this scenario, the SARS-CoV2 pandemic has caused a major disruption of healthcare systems and practices. A narrative review was conducted on articles focusing on the impact of COVID-19 on multidrug-resistant gram-negative, gram-positive bacteria, and fungi. We found that, worldwide, multiple studies reported an unexpected high incidence of infections due to methicillin-resistant S. aureus, carbapenem-resistant A. baumannii, carbapenem-resistant Enterobacteriaceae, and C. auris among COVID-19 patients admitted to the intensive care unit. In this setting, inappropriate antimicrobial exposure, environmental contamination, and discontinuation of infection control measures may have driven selection and diffusion of drug-resistant pathogens.

Impact of the COVID-19 pandemic on the incidence of multidrug-resistant bacterial infections in an acute care hospital in Brazil.

BACKGROUND: The impact of COVID-19 on healthcare- associated infections (HCAI) caused by multidrug-resistant (MDR) bacteria that contribute to higher mortality is a growing area of study METHODS: This retrospective observational study compares the incidence density (ID) of HCAI caused by MDR bacteria (CRE, CRAB, CRP, MRSA and VRE) pre-COVID (2017-2019) and during the COVID-19 pandemic (2020) in overall hospitalized patients and in intensive care (ICU) units. RESULTS: We identified 8,869 HCAI, of which 2,641 (29.7%) were caused by bacterial MDR, and 1,257 (14.1%) were from ICUs. The overall ID of MDR infections increased 23% (P < .005) during COVID-19. The overall per-pathogen analysis shows significant increases in infections by CRAB and MRSA (+108.1%, p<0.005; +94.7%, p<0.005, respectively), but not in CRE, CRP, or VRE. In the ICU, the overall ID of MDR infections decreased during COVID, but that decline was not significant (-6.5%, P = .26). The ICU per-pathogen analysis of ID of infection showed significant increases in CRAB and MRSA (+42.0%, P = .001; +46.2%, P = .04), significant decreases in CRE and CRP (-26.4%, P = .002; -44.2%, P = 0.003, respectively) and no change in VRE. CONCLUSIONS: The COVID-19 pandemic correlates to an increase in ID of CRAB and MRSA both in ICU and non-ICU setting, and a decrease in ID of CRE and CRP in the ICU setting. Infection control teams should be aware of possible outbreaks of CRAB and MRSA and promote rigorous adherence to infection control measures as practices change to accommodate changes in healthcare needs during and after the pandemic.

Co-infection of ST2IP carbapenem-resistant Acinetobacter baumannii with SARS-CoV-2 in the patients admitted to a Tehran tertiary referral hospital.

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) is among the most concerning cause of healthcare-associated infections (HAI) due to its high level of antibiotic resistance and high mortality. In the era of the COVID-19 pandemic, the key priority of infection control committees is to contain the dissemination of antibiotic resistant Gram-negative bacteria. Here, we aimed to timely recognize the emergence of CRAB in COVID-19 cases admitted to the wards of a tertiary referral hospital and to identify the genetic relatedness of the isolates. METHODS: From 30 March to 30 May 2020, a total of 242 clinical samples from COVID-19 cases were screened for CRAB isolates using standard microbiologic and antibiotic susceptibility tests. The PCRs targeting oxa23, oxa24, oxa58, blaTEM and blaNDM-1 genes were performed. Two multiplex PCRs for identifying the global clones (GC) of A. baumannii were also performed. The sequence type of CRABs was determined using Institut Pasteur (IP) multilocus sequence typing (MLST) scheme. RESULTS: Eighteen CRAB isolates were recovered from COVID-19 patients with the mean age of 63.94 ± 13.8 years. All but 4 COVID-19 patients co-infected with CRAB were suffering from an underlying disease. Death was recorded as the outcome in ICUs for 9 (50%) COVID-19 patients co-infected with CRAB. The CRAB isolates belong to GC2 and ST2IP and carried the oxa23 carbapenem resistance gene. CONCLUSION: This study demonstrated the co-infection of CRAB isolates and SARS-CoV-2 in the patients admitted to different ICUs at a referral hospital in Tehran. The CRAB isolates were found to belong to ST2IP, share the oxa23 gene and to have caused several outbreaks in the wards admitting COVID-19 patients.

The interface between COVID-19 and bacterial healthcare-associated infections.

BACKGROUND: A wide range of bacterial infections occur in coronavirus disease 2019 (COVID-19) patients, particularly in those with severe coronaviral disease. Some of these are community-acquired co-infections. OBJECTIVE: To review recent data that indicate the occurrence of hospital-onset bacterial infections, including with antibiotic-resistant isolates, in COVID-19 patients. SOURCES: Using PubMed, the literature was searched using terms including: 'COVID-19'; 'SARS-CoV-2'; 'bacterial infection'; 'healthcare-associated infection'; 'antibiotic resistance'; 'antimicrobial resistance'; 'multi-drug resistance'; 'Streptococcus'; 'Staphylococcus'; 'Pseudomonas'; 'Escherichia'; 'Klebsiella'; 'Enterococcus'; 'Acinetobacter'; 'Haemophilus'; 'MRSA'; 'VRE'; 'ESBL'; 'NDM-CRE'; 'CR-Ab'; 'VRSA'; 'MDR'. CONTENT: There is a growing number of reports of bacterial infections acquired by patients with severe COVID-19 after hospital admission. Antibiotic-resistant pathogens found to cause healthcare-associated infections (HAIs) in COVID-19 patients include methicillin-resistant Staphylococcus aureus, New Delhi metallo-ß-lactamase-producing carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, extended-spectrum ß-lactamase Klebsiella pneumoniae and vancomycin-resistant enterococci. COVID-19 has impacted bacterial HAIs in a number of ways with an increase in the incidence of New Delhi metallo-ß-lactamase-producing carbapenem-resistant Enterobacterales and carbapenem-resistant A. baumannii reported at some hospital sites compared with before the pandemic. Recommended guidelines for antimicrobial stewardship in COVID-19 patient treatment are discussed regarding minimization of empiric broad-spectrum antibiotic use. Other studies have reported a decrease in methicillin-resistant S. aureus and vancomycin-resistant enterococci cases, which has been attributed to enhanced infection prevention and control practices introduced to minimize intra-hospital spread of COVID-19. IMPLICATIONS: Poorer outcomes have been observed in hospitalized COVID-19 patients with an antibiotic-resistant infection. Although heightened IPC measures have been accompanied by a reduction in some HAIs at specific sites, in other situations, COVID-19 has been associated with an increase in bacterial HAI incidence. Further research is needed to define the cost-benefit relationship of maintaining COVID-19-related infection prevention and control protocols beyond the pandemic to reduce the burden of HAIs. In addition, the longer-term impact of high usage of certain broad-spectrum antibiotics during the COVID-19 pandemic requires evaluation.

Pre-optimized phage therapy on secondary Acinetobacter baumannii infection in four critical COVID-19 patients.

Phage therapy is recognized as a promising alternative to antibiotics in treating pulmonary bacterial infections, however, its use has not been reported for treating secondary bacterial infections during virus pandemics such as coronavirus disease 2019 (COVID-19). We enrolled 4 patients hospitalized with critical COVID-19 and pulmonary carbapenem-resistant Acinetobacter baumannii (CRAB) infections to compassionate phage therapy (at 2 successive doses of 109 plaque-forming unit phages). All patients in our COVID-19-specific intensive care unit (ICU) with CRAB positive in bronchoalveolar lavage fluid or sputum samples were eligible for study inclusion if antibiotic treatment failed to eradicate their CRAB infections. While phage susceptibility testing revealed an identical profile of CRAB strains from these patients, treatment with a pre-optimized 2-phage cocktail was associated with reduced CRAB burdens. Our results suggest the potential of phages on rapid responses to secondary CRAB outbreak in COVID-19 patients.

An outbreak of carbapenem-resistant Acinetobacter baumannii in a COVID-19 dedicated hospital.

We describe an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in a COVID-19 dedicated hospital. The suspected mechanism of transfer was an environmental source that persisted despite evacuation and terminal cleaning of the entire hospital, and transmitted through healthcare workers' hands or equipment. This outbreak demonstrates that practices to prevent the spread of multidrug-resistant organisms must not be neglected during the COVID-19 pandemic.