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

Taking hospital pathogen surveillance to the next level.

High-throughput bacterial genomic sequencing and subsequent analyses can produce large volumes of high-quality data rapidly. Advances in sequencing technology, with commensurate developments in bioinformatics, have increased the speed and efficiency with which it is possible to apply genomics to outbreak analysis and broader public health surveillance. This approach has been focused on targeted pathogenic taxa, such as Mycobacteria, and diseases corresponding to different modes of transmission, including food-and-water-borne diseases (FWDs) and sexually transmitted infections (STIs). In addition, major healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and carbapenemase-producing Klebsiella pneumoniae are the focus of research projects and initiatives to understand transmission dynamics and temporal trends on both local and global scales. Here, we discuss current and future public health priorities relating to genome-based surveillance of major healthcare-associated pathogens. We highlight the specific challenges for the surveillance of healthcare-associated infections (HAIs), and how recent technical advances might be deployed most effectively to mitigate the increasing public health burden they cause.

Efflux-Related Carbapenem Resistance in Acinetobacter baumannii Is Associated with Two-Component Regulatory Efflux Systems' Alteration and Insertion of ΔAbaR25-Type Island Fragment.

The efflux pumps, beside the class D carbapenem-hydrolysing enzymes (CHLDs), are being increasingly investigated as a mechanism of carbapenem resistance in Acinetobacter baumannii. This study investigates the contribution of efflux mechanism to carbapenem resistance in 61 acquired blaCHDL-genes-carrying A. baumannii clinical strains isolated in Warsaw, Poland. Studies were conducted using phenotypic (susceptibility testing to carbapenems ± efflux pump inhibitors (EPIs)) and molecular (determining expression levels of efflux operon with regulatory-gene and whole genome sequencing (WGS)) methods. EPIs reduced carbapenem resistance of 14/61 isolates. Upregulation (5-67-fold) of adeB was observed together with mutations in the sequences of AdeRS local and of BaeS global regulators in all 15 selected isolates. Long-read WGS of isolate no. AB96 revealed the presence of AbaR25 resistance island and its two disrupted elements: the first contained a duplicate ISAba1-blaOXA-23, and the second was located between adeR and adeA in the efflux operon. This insert was flanked by two copies of ISAba1, and one of them provides a strong promoter for adeABC, elevating the adeB expression levels. Our study for the first time reports the involvement of the insertion of the ΔAbaR25-type resistance island fragment with ISAba1 element upstream the efflux operon in the carbapenem resistance of A. baumannii.

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

Septic Episodes Caused by Acinetobacter Baumannii, Klebsiella Pneumoniae and Pseudomonas Aeruginosa in a Tertiary Hospital in 2018-2020: Trends and Considerations

Intro: This study aimed at evaluating healthcare-related sepses caused by three multi-drug resistant Gram-negative bacteria (Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa) in a tertiary hospital in 2018-2020, particularly concerning therapy, antibiotic-resistance and outcomes, by also comparing the pre-COVID (2018-2019) and COVID (2020) periods. Method(s): An observational, retrospective-cohort analysis was based on data related to patients admitted to the "SS. Antonio e Biagio e Cesare Arrigo" Hospital in Alessandria (Italy) between 2018 and 2020, with septic episodes from bacteria of the examined species, whose antibiogram proved resistance to >= 2 antimicrobial classes indicated by the European Centre for Disease Prevention and Control. Data were retrieved from patients' medical records and the hospital's computer-based application. Statistics involved Fisher-test comparisons and cumulative incidence analyses. Finding(s): Inclusion criteria led to enrolment of 174 patients. Comparison between 2020 and 2018-2019 showed a relative increase in A. baumannii cases, at the expense of the other species (p<0.0001), and an increasing resistance trend for K. pneumoniae, with a higher proportion of cases resistant to 3-4 classes of antimicrobials (p<0.0001). Overall, most patients were treated with carbapenems (72.4%), although the COVID period saw a significant rise in the use of polymyxins, particularly colistin (62.5% vs 36%, p=0.0005). In both periods, more than half patients recovered (53-57%) and around one third died (27-34%), but with different outcomes according to the infecting bacterium, generally better for P. aeruginosa (70% recovered at 60 days) and worse for A. baumannii (55% recovered). Discussion(s): The study confirmed the importance of the burden connected to healthcare-related sepses. Moreover, since the COVID outbreak, a trend could be spotted towards higher relative incidence of complex cases, caused by antimicrobial-resistant bacteria and thus requiring second-line therapy. Conclusion(s): These findings underline the importance of appropriate antimicrobial stewardship and infection control in view of the evolving healthcare needs.Copyright © 2023

Emergence of Colistin Resistance of Mdr Acinetobacter Spp. In Hospital Sungai Buloh during Covid-19 Pandemic

Intro: Acinetobacter calcoaceticus - A.baumannii complex is an opportunistic pathogen that has emerged as one of the multidrug resistant organism frequently associated with nosocomial infections especially causing ventilator- associated pneumonia (VAP). Colistin and Polymyxin B are currently being used as salvage therapy for treating MDR Acinetobacter spp. However, the emergence of resistance of colistin has been reported and treatment is further complicated by poor lung tissue penetration. Thus, we implied to explore on the prevalence of its resistance in our own facility, being the national COVID-19 referral hospital. Method(s): This is a cross-sectional retrospective analysis of MDR Acinetobacter spp. done for isolates of 2019 and 2021. Only clinically significant isolates were sent to Institute of Medical Research (IMR) for colistin susceptibility testing by broth microdilution. The identification of the isolates was performed by Bruker MALDI-ToF. CLSI breakpoints were used to determine susceptibility, applying the change of breakpoints interpretation in year 2020. Finding(s): In 2021, out of 203 isolates, 195 (96%) were Acinetobacter baumannii. Other spp. isolated were A. nosocomialis (6, 3%) and A. proteolyticus (2, 1%). Out of that, 107 (52.7%) were resistant with MIC of >4 ug/ml and 96 (47.3 %) were intermediate with MIC of <2 ug/ml. Pre-pandemic, resistance rates were compared with 2019 and this showed 47% were resistant with MIC of >4 ug/ml and 52% were susceptible with MIC <2 ug/ml. Clinical characteristics of patients were analysed;previous use of carbapenem, ventilation history, length of stay, and outcome (alive or deceased). Most of patients were severely ill with majority of admissions due to Category 4-5 COVID-19 and required ventilation in critical care unit. Previous carbapenem exposure was not significantly associated with colistin resistance (p=0.936). Conclusion(s): Emergence of colistin resistant MDR Acinetobacter spp. is alarming. Infection control measures are crucial and other therapeutic options need to be explored to improve quality of care.Copyright © 2023

Antibiotic resistance of Klebsiella pneumoniae against the background of the COVID-19 pandemic: experience of the multidisciplinary hospital

Frequency of bacterial co-infections among patients with COVID-19 is not high, and over-prescribing of antibiotics may contribute the selection of resistant strains of enterobacteria and gram-negative non-fermenting bacteria. The aim of the study was to assess the local features of antibiotic resistance of K. pneumoniae and its genetic mechanisms against background of the COVID-19 infection pandemic. Material and methods. There was selected 37 carbapenem-resistant K. pneumoniae strains isolated in 2016, 2017 and 2020 from hospitalized patients, including 15 strains, isolated from patients with COVID-19 infection. Minimal inhibitory concentrations (MICs) of meropenem and colistin were determined by broth microdilution method. Determination of MICs of eravacycline, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam was performed using Sensititre diagnostic system on EUMDROXF plates. Susceptibility to 11 combinations of 2 antibiotics was detected by modified method of multiply combination bactericidal testing. For 4 K. pneumoniae strains high-throughput sequencing was performed, followed with the subsequent search for determinants of antibiotic resistance and virulence, assessment of plasmid profiles. Results. All strains were resistant to meropenem (MIC50 32 mg/l, MIC90 128 mg/l) and produced KPC and OXA-48 carbapenemases. Strains isolated in 2016-2017 were susceptible to colistin (MIC <=2 mg/l), in 2020 only 26.7% of the strains retained their susceptibility (MIC50 64 mg/l, MIC90 256 mg/l). Susceptibility to combinations of two antibiotics with colistin included reduced from 84.6-100% in 2016-2017 till 26.6-66.7% in 2020. The strains isolated in 2020 retained their susceptibility to ceftazidime/avibactam (MIC <=1 mg/l). 5 strains resistant to cefiderocol with a MIC 8 mg/l were identified. Strains 2564 and 3125 isolated in 2020 from sputum of patients with COVID-19 infection belonged to different sequence-types (ST12 and ST23) and contained the blaOXA-48 carbapenemase gene, additionally strain 2564 contained the blaKPC-27carbapenemase gene. Resistance to colistin was caused by inactivation of the mgrB genes due to insertion of IS1 and IS5-like transposons. Conclusion. The performed genetic studies demonstrate a diversity of mechanisms of antibiotic resistance in K. pneumoniae leading to the formation of resistance including to antibiotics that haven't been used in Belarus till now.Copyright © 2021 Geotar Media Publishing Group. All Rights Reserved.

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

Rapid Diagnostics in Infection Prevention

There are several relevant pathogens in healthcare today that are easily transmissible among populations and are associated with significant morbidity and mortality. In order to decrease transmission, it is important to identify infected patients quickly so that infection prevention techniques can be employed. Rapid diagnostic tests assist with this as they often produce results 24-48 h faster than traditional culture and sensitivity methods. This chapter discusses the benefits and limitations of rapid diagnostic tests overall, as well as considerations for rapid diagnostics for carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridioides difficile, Candida auris, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and influenza. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Carbapenem Heteroresistance Mdr Enterobacter Cloacae in a Post-Covid-19 Obese Patient: An Antibiotic Susceptibility Conversion

Intro: Background: Obesity affects drug delivery and clearance owing to the patient's altered pharmacokinetics. In treating infection, this presents as a conundrum antibiotic dosing to achieve optimal antibiotic concentration at the same time avoiding drug toxicity. Particularly in the case of antimicrobial agents, underdosing may lead to antibiotic resistance. Method(s): Case description: We report a case of a morbidly obese (BMI=58) COVID-19 patient infected with carbapenem-sensitive multi-drug resistant (MDR) Enterobacter cloacae bacteremia, treated with ertapenem 1g twice daily and intravenous polymyxin E 9MU stat and 4.5MU twice daily for MDR Acinetobacter baumanii co-infection. He had infected huge grade IV sacral sore one month later in which intraoperative tissue culture grew phenotypically heterogeneous colonies of MDR Enterobacter cloacae with carbapenem-sensitive and carbapenem-intermediate-resistant non-carbapenemase producing colonies. He responded well clinically and biochemically with an increased dose of intravenous ciprofloxacin 800mg BD based on his actual body weight. He was discharged with oral ciprofloxacin 750mg BD for a total of six weeks. Finding(s): Discussion: Obesity is a public health crisis that has reached epidemic proportions. Obesity affects the volume distribution and renal clearance of many drugs including antibiotics. Obese patients are shown to have higher drug clearance than normal-weighted patients resulting in inadequate systemic exposure. This puts patients at risk of developing antibiotic resistant organisms. Our patient, weighing 162kg was given three different beta-lactam antibiotics to treat his infection including ertapenem in which a standard adult dose was given without body weight consideration. Possible underdosing contributed to the conversion of carbapenem susceptibility from sensitive to resistant strain. Conclusion(s): Obese individuals may need a larger ertapenem dose than their non-obese counterparts. Clinical and laboratory assessment may help in monitoring treatment response in this group of patients.Copyright © 2023

Neonates with Maternal Colonization of Carbapenemase-Producing, Carbapenem-Resistant Enterobacteriaceae: A Mini-Review and a Suggested Guide for Preventing Neonatal Infection.

Carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) are highly drug-resistant Gram-negative bacteria. They include New Delhi metallo-ß-lactamase (NDM)-producing carbapenemase (50.4% of all species in Ontario). Antibiotic challenges for resistant bacteria in neonates pose challenges of unknown dosing and side effects. We report two antenatally diagnosed CP-CRE colonization scenarios with the NDM 1 gene. The case involves extreme preterm twins who had worsening respiratory distress at birth requiring ventilator support, with the first twin also having cardiovascular instability. They were screened for CP-CRE, and a polymyxin antibiotic commenced. In the delivery room, neonatal intensive care unit (NICU) and the follow-up clinic, in collaboration with the interdisciplinary group, contact precautions and isolation procedures were instituted. None of the infants exhibited infection with CP-CRE. Consolidating knowledge with regard to CP-CRE and modifying human behavior associated with its spread can mitigate potential negative consequences. This relates to now and later, when travel and prolific human to human contact resumes, from endemic countries, after the current COVID-19 pandemic. Standardized efforts to curb the acquisition of this infection would be judicious given the challenges of treatment and continued emerging antibiotic resistance. Simple infection control measures involving contact precautions, staff education and parental cohorting can be useful and cost-effective in preventing transmission. Attention to NICU specific measures, including screening of at-risk mothers (invitro fertilization conception) and their probands, careful handling of breastmilk, judicious antibiotic choice and duration of treatment, is warranted. What does this study add? CP-CRE is a nosocomial infection with increasing incidence globally, and a serious threat to public health, making it likely that these cases will present with greater frequency to the NICU team. Only a few similar cases have been reported in the neonatal literature. Current published guidelines provide a framework for general hospital management. Still, they are not specific to the NICU experience and the need to manage the parents' exposure and the infants. This article provides a holistic framework for managing confirmed or suspected cases of CP-CRE from the antenatal care through the NICU and into the follow-up clinic targeted at preventing or containing the spread of CP-CRE.

Molecular epidemiology of carbapenem-resistant Enterobacteriaceae isolated from patients in COVID-19 wards and ICUs in a Bulgarian University Hospital.

Many studies report an increase in antimicrobial resistance of Gram - negative bacteria during the COVID-19 pandemic. Our aim was to evaluate the epidemiological relationship between carbapenem-resistant (CR) Enterobacteriaceae isolates from patients in COVID-19 wards and to investigate the main mechanisms of carbapenem resistance in these isolates during the period April 2020-July 2021. A total of 45 isolates were studied: Klebsiella pneumoniae (n = 37), Klebsiella oxytoca (n = 2), Enterobacter cloacae complex (n = 4) and Escherichia coli (n = 2). Multiplex PCR was used for detection of genes encoding carbapenemases from different classes (blaKPC, blaIMP, blaVIM, blaNDM, blaOXA-48). For epidemiological typing and analysis, ERIC PCR was performed. Two clinical isolates of E. cloacae, previously identified as representatives of two dominant hospital clones from the period 2014-2017, were included in the study for comparison. In the CR K. pneumoniae group, 23 (62.2%) carried blaKPC, 13 (35.1%) blaNDM, 10 (27.0%) blaVIM, and 9 (24.3%) were positive for both blaKPC and blaVIM. The blaKPC was identified also in the two isolates of K. oxytoca and blaVIM in all E. cloacae complex isolates. The two CR isolates of E. coli possessed blaKPC and blaOXA-48 genes. Epidemiological typing identified 18 ERIC profiles among K. pneumoniae, some presented as clusters of identical and/or closely related isolates. The carbapenem resistance in the studied collection of isolates is mediated mainly by blaKPC. During the COVID-19 pandemic intrahospital dissemination of CR K. pneumoniae, producing carbapenemases of different molecular classes, as well as continuing circulation of dominant hospital clones of multidrug-resistant E. cloacae complex was documented.

Evaluation of risk factors associated with mortality in patients with ventilator-associated pneumonia caused by Pseudomonas aeruginosa with difficult-to-treat resistance

Introduction: Evaluation of prognostic factors in patients with ventilator- associated pneumonia (VAP) due to P. aeruginosa. The effectiveness of novel antipseudomonal antibiotics was reviewed. Method(s): Retrospective, single-center cohort analysis between April 2018 and June 2022. Data were obtained from the ENVIN-HELICS and electronic medical records. Demographic variables, underlying diseases and diagnosis to admission were registered. We considered each treatment appropriate according to Tamma PD et al. [1] criteria. We registered ventilator-associated tracheobronchitis (VAT) and pneumonia (VAP) episodes together with the recurrency of the infection. Result(s): From 61 patients included, 77% were admitted for ARDS due to COVID-19. The mean APACHE-II was 14.3 +/- 6.6. 7 patients required ECMO and 4 required RRT. The median length of stay in the ICU was 52 (ICR 36-84) days. 91 respiratory infections were recorded: 60 VAP and 31 VAT. On the first episode, carbapenem-resistance to meropenem was 40%;rising up to 58% on the second one. 6 patients developed a third episode (VAT) with a 100% of carbapenem- resistance. 13 (14%) respiratory infections showed resistance to the novel beta-lactamase inhibitor cephalosporins (8 to ceftalozanetazobactam and 5 to ceftazidime-avibactam). No resistance to cefiderocol was detected. During ICU stay, 21 patients (34%) developed secondary bacteremia from other foci and 7 (11%) invasive mycoses. Overall mortality was 49.2%. On the univariate analysis we found statistical significant relationships between mortality and COVID-19 admission, SOFA >= 7 points on the first VAP or the development of secondary bacteremia (Table 1). Conclusion(s): COVID-19 admission, SOFA >= 7 points on the first VAP or other secondary bacteremia were associated with mortality. The 14.3% of respiratory infections were resistant to the new beta-lactamase inhibitor cephalosporins. No resistance to cefiderocol was detected.

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.

Epidemiology of multidrug-resistant organisms before and during COVID-19 in Hong Kong.

Background: The coronavirus disease 2019 (COVID-19) has influenced antimicrobial consumption and incidence of multidrug-resistant organisms (MDROs). We aimed to study the epidemiology of MDROs before and during the COVID-19 pandemic in Hong Kong. Methods: With the maintenance of infection control measures, we described the trend of MDRO infections, including methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum-beta-lactamase-(ESBL)-producing Enterobacterales, in a healthcare region with 3100-bed before (1 January 2016 to 31 December 2019, period 1) and during COVID-19 (1 January 2020 to 30 September 2022, period 2), together with the antimicrobial consumption using piecewise Poisson regression. The epidemiological characteristics of newly diagnosed COVID-19 patients with or without MDRO infections were analyzed. Results: Between period 1 and 2, we observed a significant increase in the trend of CRA infections (P<0.001), while there was no significant increase in the trend of MRSA (P=0.742) and ESBL-producing Enterobacterales (P=0.061) infections. Meanwhile, a significant increase in the trend of carbapenems (P<0.001), extended-spectrum beta-lactam-beta-lactamase inhibitor combinations (BLBI) (P=0.045), and fluoroquinolones (P=0.009) consumption was observed. The observed opportunity (23,540 ± 3703 vs 26,145 ± 2838, p=0.359) and compliance (81.6% ± 0.5% vs 80.1% ± 0.8%, P=0.209) of hand hygiene per year was maintained. In a multivariable model, older age, male sex, referral from residential care home for the elderly, presence of indwelling device, presence of endotracheal tube, and use of carbapenems, use of BLBI, use of proton pump inhibitors and history of hospitalization in the past 3 months were associated with higher risks of infections by MDROs among COVID-19 patients. Conclusion: Infection control measures may control the surge of MDROs despite an increasing trend of antimicrobial consumption.

Molecular Characterization of the Convergent Carbapenem-Resistant and Hypervirulent Klebsiella pneumoniae Strain K1-ST23, Collected in Chile during the COVID-19 Pandemic.

The aim of this study was to investigate the genomic features of a carbapenem-resistant hypervirulent Klebsiella pneumoniae (CR-hvKp) isolate (K-2157) collected in Chile. Antibiotic susceptibility was determined using the disk diffusion and broth microdilution methods. Whole-genome sequencing (WGS) and hybrid assembly were performed, using data generated on the Illumina and Nanopore platforms. The mucoid phenotype was analyzed using both the string test and sedimentation profile. The genomic features of K-2157 (e.g., sequence type, K locus, and mobile genetic elements) were retrieved using different bioinformatic tools. Strain K-2157 exhibited resistance to carbapenems and was identified as a high-risk virulent clone belonging to capsular serotype K1 and sequence type 23 (ST23). Strikingly, K-2157 displayed a resistome composed of ß-lactam resistance genes (blaSHV-190, blaTEM-1, blaOXA-9, and blaKPC-2), the fosfomycin resistance gene fosA, and the fluoroquinolones resistance genes oqxA and oqxB. Moreover, several genes involved in siderophore biosynthesis (ybt, iro, and iuc), bacteriocins (clb), and capsule hyperproduction (plasmid-borne rmpA [prmpA] and prmpA2) were found, which is congruent with the positive string test displayed by K-2157. In addition, K-2157 harbored two plasmids: one of 113,644 bp (KPC+) and another of 230,602 bp, containing virulence genes, in addition to an integrative and conjugative element (ICE) embedded on its chromosome, revealing that the presence of these mobile genetic elements mediates the convergence between virulence and antibiotic resistance. Our report is the first genomic characterization of a hypervirulent and highly resistant K. pneumoniae isolate in Chile, which was collected during the coronavirus disease 2019 (COVID-19) pandemic. Due to their global dissemination and public health impact, genomic surveillance of the spread of convergent high-risk K1-ST23 K. pneumoniae clones should be highly prioritized. IMPORTANCE Klebsiella pneumoniae is a resistant pathogen involved primarily in hospital-acquired infections. This pathogen is characterized by its notorious resistance to last-line antibiotics, such as carbapenems. Moreover, hypervirulent K. pneumoniae (hvKp) isolates, first identified in Southeast Asia, have emerged globally and are able to cause infections in healthy people. Alarmingly, isolates displaying a convergence phenotype of carbapenem resistance and hypervirulence have been detected in several countries, representing a serious threat to public health. In this work, we analyzed the genomic characteristics of a carbapenem-resistant hvKp isolate recovered in 2022 from a patient with COVID-19 in Chile, representing the first analysis of this type in the country. Our results will provide a baseline for the study of these isolates in Chile, which will support the adoption of local measures aimed at controlling their dissemination.

Microbiological monitoring of COVID-19 patients in the ICU: a prospective observational study.

Objective. To study spectrum of pathogens and the time to colonization of respiratory samples in patients with severe and critical COVID-19 as well as to analyze incidence of nosocomial infections and structure of prescribed antibacterial drugs. Materials and methods. The prospective observational study included patients aged 18 years and older with confirmed severe and critical COVID-19 from December 2021 to February 2022. During the first 48 hours and then every 2-3 days of hospitalization, a respiratory sample was collected: sputum, tracheal aspirate (if intubated), bronchoalveolar lavage (if bronchoscopy was performed) for microscopy and microbiological examination. Some patients were screened for invasive aspergillosis. Clinical and demographic data, comorbidities, pathogenetic therapy for COVID-19, antibiotic therapy, cases of probable/documented bacterial nosocomial infections, antibiotic-associated diarrhea, and hospital treatment outcomes were recorded. Results. A total of 82 patients were included in this study. Patients with lung parenchyma involvement of more than 50% by computer tomography predominated;most of them (77%) required intubation and mechanical ventilation due to progression of respiratory failure, and 76% of patients had a lethal outcome. During the first 48 hours, a respiratory sample was obtained from 47 patients;the rest of the patients presented with non-productive cough. No growth of microorganisms was detected in 31 (36.8%) cases;clinically significant pathogens were detected in 16 (19.5%) patients. A subsequent analysis included data from 63 patients with a sufficient number of samples for dynamic observation were used. During the first 3 days of ICU stay, the most common bacterial pathogens were Klebsiella pneumoniae without acquired antibiotic resistance and methicillin-susceptible Staphylococcus aureus. From 3rd day and afterwards, an increase in the proportion of Acinetobacter baumannii, other non-fermenting bacteria, and carbapenem-resistant Enterobacterales was noted. Among the pathogens causing lower respiratory tract infections, A. baumannii and carbapenem-resistant K. pneumoniae were predominant pathogens and accounted for 76% of cases. Positive galactomannan test results were obtained in 4 cases. Conclusions. The study confirmed importance of bacterial nosocomial infections in patients with severe and critical COVID-19. In the case of the development of nosocomial lower respiratory tract infections, empirical antimicrobial therapy should take into account the predominance of carbapenem-resistant Enterobacteria and A. baumannii, as well as the possibility of invasive aspergillosis.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.