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.

Reducing the Risk of Perioperative Transmission of Candida auris: The Official Voice of Perioperative Nursing

CAUSES OF C AURIS TRANSMISSION In 2009, laboratory personnel isolated C auris from discharge originating in the external ear canal of a hospitalized patient in Japan and named it accordingly.5 Although C auris is closely related to other Candida species, it behaves much differently;rather than originating in the host's flora, it is most often acquired through contact with contaminated surfaces or fomites shed from colonized or infected individuals.6 Patients infected or colonized with C auris shed the pathogen from their skin, which can contaminate the environment-including shared medical equipment.7 Because the pathogen can remain viable on surfaces for prolonged periods (eg, four weeks8), it can be transmitted to patients and lead to systemic infection.9 Traditional biochemical tests for yeast identification may misidentify C auris as another yeast,9,10 and ineffective environmental cleaning can allow it to persist on surfaces, thereby increasing the risk of an outbreak.9 The first reported health care-associated C auris outbreak occurred between April 2015 and July 2016 in a cardiothoracic center in London.11 In June 2016, the CDC issued a clinical alert to health care facilities, noting that one isolate of C auris was detected in 2013 and that the pathogen had been in identified in nine countries on four continents since 2009.12 The number of clinical C auris cases has increased each year since 2016;from 2020 to 2021, that number almost doubled (755 to 1,470).13 In December 2022, there were 1,994 clinical cases and 5,071 screening cases (ie, indicating colonization) of C auris in the United States, with the highest incidence in California, Florida, Illinois, Nevada, New York, and Texas.13 In contrast, from 2013 to 2016, there had only been 63 clinical cases and 14 screening cases reported, occurring only in Illinois, Maryland, New Jersey, and New York. The patient risk factors for acquiring C auris are comparable to those associated with other types of Candida infections, such as Candida albicans, and include * recent surgery,4 * hospitalization in an endemic country outside the United States,4 * extended stays in an intensive care unit,17 * recent care in a postacute setting (eg, long-term care facility),4 * recent therapy with broad-spectrum antimicrobials,4 * the presence of invasive medical devices (eg, central venous catheter, feeding tube, endotracheal tube),4 and * chronic conditions or immunosuppression.18 The risk of healthy individuals (eg, health care workers [HCWs]) contracting C auris is very low. STRATEGIES TO CONSIDER Preventing transmission of epidemiologically important pathogens, such as C auris, in the perioperative practice setting requires strict compliance with infection prevention and control (IPC) measures, including * adhering to hand hygiene requirements, * using transmission-based (ie, contact) precautions, * communicating effectively, and * cleaning and disinfecting the health care environment with approved products.23 In addition, appropriate screening to identify patients colonized or infected with C auris and laboratory surveillance to identify the pathogen also are needed. When caring for patients with possible or confirmed C auris colonization or infection, HCWs should use contact precautions in addition to standard precautions.23 When implementing contact precautions in perioperative areas, personnel should consult with a facility infection preventionist on required personal protective equipment (PPE), patient transport protocol, patient placement in the facility, and enhanced environmental cleaning practices.25 Effective communication may help to ensure that HCWs implement IPC measures correctly and consistently.

Impact of a Pro-Active Infectious Disease Consultation on the Management of a Multidrug-Resistant Organisms Outbreak in a COVID-19 Hospital: A Three-Months Quasi-Experimental Study.

BACKGROUND: Antimicrobial and diagnostic stewardship (AS/DS) principles are crucial for the management of multidrug-resistant organisms (MDROs) infections. We evaluated the impact of a pro-active Infectious Disease (ID) consultation on the mortality risk of patients during an MDROs outbreak in a COVID-19 hospital. METHODS: A quasi-experimental study was performed in a dedicated COVID-19 hospital, including patients with suspected/confirmed infection and/or colonization by MDROs, which were managed as follows: (i) according to the standard of care during the pre-phase and (ii) in collaboration with a dedicated ID team performing a pro-active bedside evaluation every 48-72 h in the post-phase. RESULTS: Overall, 112 patients were included (pre-phase = 89 and post-phase = 45). The AS interventions included the following: therapy optimization (33%), de-escalation to narrow the spectrum (24%) or to lessen toxic drugs (20%), and discontinuation of antimicrobials (64%). DS included the request of additional microbiologic tests (82%) and instrumental exams (16%). With the Cox model, after adjusting for age, sex, COVID-19 severity, infection source, etiological agents, and post-phase attendance, only age predicted an increased risk of mortality, while attendance in the post-phase resulted in a decreased risk of mortality. CONCLUSIONS: Implementation of AS and DS intervention through a pro-active ID consultation may reduce the risk of 28-day mortality of COVID-19 patients with MDROs infections.

SG-APSIC1064: The role of infection control activities on healthcare-associated infections during 2017-2021 at intensive care units in Cho Ray Hospital

Objectives: Healthcare-associated infections (HAIs) are one of the greatest challenges and concerns in Vietnam and around the world. Many studies have shown that HAIs may result in an increase in hospital length of stay, antibiotic use, multidrug-resistant organism (MDROs) infections, treatment costs, and mortality. Therefore, in the past 5 years, the Department of Infection Control of Cho Ray Hospital has carried out many infection and prevention control (IPC) activities to reduce the rates of HAI and MDRO infection. We evaluated IPC activities and results achieved in these efforts at Cho Ray Hospital during 2017–2021. Methods: We described the implemented IPC activities and retrospectively collected data from HAIs surveillance reports during 2017–2021 for 3 intensive care units (ICUs): ICU-B, ICU-D, and the NICU. Results: In the past 5 years, we implemented synchronous IPC activities, including promoting hand hygiene training and surveillance, environmental cleaning surveillance, carrying out improvement projects such as a ventilator-associated pneumonia (VAP) prevention bundle, an MDRO prevention bundle, and an environmental cleaning quality improvement project. Many positive results were achieved, although a slight increase in the HAI incidence occurred in 2021 due to the COVID-19 pandemic. Overall, the hand hygiene compliance rate increased from 49.7% to 83.8%. The rate of HAIs per 1,000 patient days decreased steadily from 5.4 to 2.4. The VAP rate fell from 30.5 to 17.2 per 1,000 patient days, and the central-line–associated bloodstream infection (CLABSI) rate decreased gradually from 5.4 to 2.4 per 1,000 patient days. The catheter-associated urinary tract infection (CAUTI) rate decreased from 2.9 to 0.9 per 1,000 patient days, and the MDRO infection rate decreased significantly from 32.7 to 11.3 per 1,000 patient days. Conclusions: The synchronous implementation of HAI prevention bundles promoting hand hygiene and environmental cleaning achieved significant effects in the efforts to decrease HAIs and MDROs in the ICUs of Cho Ray Hospital.

Epidemiological Characteristics and Antimicrobial Resistance Changes of Carbapenem-Resistant Klebsiella pneumoniae and Acinetobacter baumannii under the COVID-19 Outbreak: An Interrupted Time Series Analysis in a Large Teaching Hospital.

BACKGROUND: To investigate the epidemiological characteristics and resistance changes of carbapenem-resistant organisms (CROs) under the COVID-19 outbreak to provide evidence for precise prevention and control measures against hospital-acquired infections during the pandemic. METHODS: The distribution characteristics of CROs (i.e., carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii) were analyzed by collecting the results of the antibiotic susceptibility tests of diagnostic isolates from all patients. Using interrupted time series analysis, we applied Poisson and linear segmented regression models to evaluate the effects of COVID-19 on the numbers and drug resistance of CROs. We also conducted a stratified analysis using the Cochran-Mantel-Haenszel test. RESULTS: The resistance rate of carbapenem-resistant Acinetobacter baumannii (CRAB) was 38.73% higher after the COVID-19 outbreak compared with before (p < 0.05). In addition, the long-term effect indicated that the prevalence of CRAB had a decreasing trend (p < 0.05). However, the overall resistance rate of Klebsiella pneumoniae did not significantly change after the COVID-19 outbreak. Stratified analysis revealed that the carbapenem-resistant Klebsiella pneumoniae (CRKP) rate increased in females (OR = 1.98, p < 0.05), those over 65 years old (OR = 1.49, p < 0.05), those with sputum samples (OR = 1.40, p < 0.05), and those in the neurology group (OR = 2.14, p < 0.05). CONCLUSION: The COVID-19 pandemic has affected the change in nosocomial infections and resistance rates in CROs, highlighting the need for hospitals to closely monitor CROs, especially in high-risk populations and clinical departments. It is possible that lower adherence to infection control in crowded wards and staffing shortages may have contributed to this trend during the COVID-19 pandemic, which warrants further research.

Bacterial contamination on used face masks in healthcare personnel

Background: Face masks have been worn universally and for long periods of time by healthcare personnel during the COVID-19 pandemic. They are frequently touched or adjusted with the hands and may come in contact with various surfaces and high-touch sites when taken off and on even briefly. These activities present opportunities for face masks to become contaminated with microorganisms. Nursing homes have high rates of multidrug-resistant bacteria and low PPE compliance;therefore, contamination of face masks in this setting may be of great interest. We investigated bacterial colonization status on used face masks in healthcare personnel, including assessing the presence of clinically important and multidrug-resistant bacteria. Methods: At a nursing home serving mostly post–acute-care patients, we collected 69 face masks from personnel at the end of the user's work shift. Information about the mask and the user was also collected via a self-reported survey. Face masks were incubated in BHI broth overnight at 36°C and 10 μL was then plated on selective and differential plates. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and gram-negative bacteria (GNB) resistant to several antibiotic classes were identified using standard microbiological methods. Resistance testing for cefoxitin (S. aureus), ciprofloxacin, meropenem, tetracycline, erythromycin, gentamicin, trimethoprim–sulfamethoxazole, and ceftazidime with and without clavulanic acid (gram-negative bacteria) was performed using the disc diffusion technique on Mueller-Hinton plates (Kirby Bauer). Results: The job categories of face mask users were competency-evaluated nursing assistant or nursing assistant (22.73%), nurse (12.12%), and other or administrative (37.88%). Overall face mask contamination rates for MRSA (0%) and VRE (3.3%) were low;however, methicillin-susceptible S. aureus was found on 11 masks (15.9%). High contamination and resistance rates were found for gram-negative bacteria, with 113 isolates. Among them, 69 (60.9%) were resistant to at least 1 antibiotic, most commonly was erythromycin (59.4%). Additionally, higher rates of clinically important pathogenic gram-negative bacteria were identified: 14.3% of masks were contaminated with Klebsiella pneumoniae, 13.0% were contaminated with Enterobacter spp, and 4.2% were contaminated with Escherichia coli. Importantly, there were no significant differences in the total number of isolates of potential clinical significance recovered from masks worn >6 hours versus those worn <6 hours. Conclusions: Among nursing-home healthcare workers, face masks were often contaminated with multiple organisms, including potentially pathogenic bacteria and antibiotic-resistant gram-negative organisms. This contamination may pose a risk for transmission if face masks are not properly used and/or disposed of after wearing. Prolonged duration of face-mask wearing, however, was not associated with increased contamination rates.Funding: NoneDisclosures: None

Characteristics of patients positive for COVID-19 and multidrug-resistant organisms in Tennessee, 2020–2021

Background: Multidrug-resistant organisms (MDROs) are a global threat. To track and contain the spread, the Tennessee Department of Health (TDH) performs targeted surveillance of carbapenemase-producing and pan-nonsusceptible organisms. When these MDROs are identified, TDH conducts a containment response and collects epidemiological data, which includes risk factors such as indwelling devices and previous hospitalizations. The impact of the COVID-19 pandemic on these MDROs is not well understood. Therefore, we have described the characteristics of cases positive for both COVID-19 and select MDROs. Methods: MDRO investigation data from January 1, 2020–September 30, 2021 were matched with all COVID-19 case data from the TDH statewide surveillance system, National Electronic Disease Surveillance System Base System. MDRO-positive date was defined as the specimen collection date;COVID-19 case date was first defined as the date of symptom onset and if missing, then diagnosis date, and investigation creation date, respectively. Descriptive statistics and Fisher exact tests were calculated using SAS version 9.4 software. Results: Among 336 MDRO cases, 50 had a reported SARS-CoV-2–positive result. MDRO types were Enterobacterales (CRE) (n = 31), Acinetobacter spp (CRA) (n = 18), and Pseudomonas aeruginosa (n = 1). Of these 50 cases, 20 were MDRO-positive before and 30 days after the COVID-19 case date, respectively. Of the 18 CRA cases, 16 (89%), were positive after the COVID-19 case date, compared to 13 (42%) among 31 CRE cases (P < .01). Also, 35 patients (70%) had a record of hospitalization, and 22 (63%) had their MDRO specimen collected after the COVID-19 case date (P = .37). Of these 22 patients, 4 had their MDRO specimen collected during their COVID-19 hospitalization, with an average duration from admission to MDRO collection date of 17 days (range, 4–36). Among the 50 coinfected cases, 8 died, 7 (88%) of whom were MDRO-positive after their COVID-19 case date. Data on indwelling devices at time of MDRO positivity were completed for 17 cases;14 had an indwelling device and, among these, 13 (93%) were MDRO-positive after their COVID-19 case date. Conclusions: MDRO cases with specimen collections after COVID-19 comprised the majority of hospitalized patients, patients who died, and patients with indwelling devices compared to those with MDROs collected before their COVID-19 case date. These results show a stark difference with CRA as the most common MDRO among post–COVID-19 cases. Our data were limited by reporting gaps. We recognize that patients can remain colonized with MDROs for lengthy durations, which could have result in undetected MDRO cases prior to the COVID-19 case date. More data and analyses are needed to make targeted public health recommendations. However, these findings highlight the burden of MDROs among COVID-19 cases. including adverse health outcomes.Funding: NoneDisclosures: None

Outbreak response activities conducted by public health programs in healthcare facilities nationwide, August 2019–July 2020

Background: Rapid response is critical to control healthcare-associated infection (HAI) and antibiotic resistance threats within healthcare facilities to prevent illness among patients, residents, and healthcare personnel. Through this analysis, we aimed to quantify public health response activities, by healthcare setting type, for (1) novel and targeted multidrug-resistant organisms or mechanisms (MDROs), (2) SARS-CoV-2, and (3) other possible outbreaks. Method: We reviewed response activity data submitted by US state, territorial, and local health department HAI/AR programs to the CDC as part of funding requirements. We performed descriptive analyses of response activities conducted during the funding reporting period (August 2019–July 2020). SARS-CoV-2 response activities were reported from January through July 2020. Data were analyzed by response category (novel or targeted MDRO, SARS-CoV-2, other HAI/AR responses), and healthcare setting type. Results: During August 2019–July 2020, 57 HAI/AR Programs (50 state, 1 territorial, 5 local health departments, and District of Columbia) reported 18,306 public health responses involving healthcare facilities. These data included 3,860 responses to 1 or more cases of novel or targeted MDROs, 13,992 responses to SARS-CoV-2 outbreaks (beginning in January 2020), and 454 responses to other possible outbreaks. Novel and targeted MDRO responses most frequently occurred in acute-care hospitals (ACHs, 64.5%), skilled nursing facilities (SNFs, 24.5%), and long-term acute-care hospitals (LTACHs, 5.8%). SARS-CoV-2 responses most frequently occurred in SNFs (55%), and assisted living facilities (24%). Other HAI/AR responses most frequently occurred in ACH (50%), SNF (28.4%), and outpatient settings (19.6%). Of the "other” HAI/AR responses, 76% were responses to cases, clusters, or outbreaks, and 23.8% were responses to serious infection control breaches including device and instrument reprocessing, injection safety, and other deficient practices. Conclusions: During the study period, public health programs performed a high volume of HAI/AR response activities largely focused on SARS-CoV-2 in nursing homes and assisted living facilities. Other important response activities occurred across a range of other healthcare settings, including responses to novel and targeted MDROs, HAI outbreaks, and serious infection control breaches. Whereas SARS-CoV-2 response activities largely centered in long-term care settings, MDRO and other HAI/AR responses occurred mostly in acute-care settings. These data demonstrate the importance of building and sustaining public health response capacity for a broad array of healthcare settings, pathogens, and patient populations to meet the range of current and emerging HAI/AR threats.Funding: NoneDisclosures: None

A review of four cases of COVID-19 medically evacuated by ambulance jet from Asian countries to Japan: Importance of strict infection control measures against multidrug-resistant organisms.

International medical evacuation, which is an option to receive better medical care for travelers with emergencies staying in low- and middle-income countries, has been more challenging during the coronavirus disease 2019 (COVID-19) pandemic. We herein discuss our experience with four Japanese patients with COVID-19 who required medical evacuation from Asian countries during the pandemic. Of these, none of the patients had received a COVID-19 vaccine; three patients needed oxygen therapy on admission to our hospital; and one patient died due to respiratory failure on day 50 after hospitalization. It was observed that multidrug-resistant organisms were colonized in two patients after obtaining culture results based on active surveillance. Strict infection control measures against multidrug-resistant organisms should be implemented during the care of patients with COVID-19 who require medical evacuation from high-risk countries. Further, it is important to communicate timely updates regarding the patient's condition with travel assistance agencies as the patient's condition may rapidly change during the course of arranging the evacuation.

Artificial intelligence in overcoming rifampicin resistant-screening challenges in Indonesia: a qualitative study on the user experience of CUHAS-ROBUST

Purpose>The Chulalongkorn-Hasanuddin Rifampicin-Resistant Tuberculosis Screening Tool (CUHAS-ROBUST) is an artificial intelligence–based (AI–based) application for rifampicin-resistant tuberculosis (RR-TB) screening. This study aims to elaborate on the drug-resistant TB (DR-TB) problem and the impact of CUHAS-ROBUST implementation on RR-TB screening.Design/methodology/approach>A qualitative approach with content analysis was performed from September 2020 to October 2020. Medical staff from the primary care center were invited online for application trials and in-depth video call interviews. Transcripts were derived as a data source. An inductive thematic data saturation technique was conducted. Descriptive data of participants, user experience and the impact on the health service were summarizedFindings>A total of 33 participants were selected from eight major islands in Indonesia. The findings show that DR-TB is a new threat, and its diagnosis faces obstacles particularly prolonged waiting time and inevitable delayed treatment. Despite overcoming the RR-TB screening problems with fast prediction, the dubious screening performance, and the reliability of data collection for input parameters were the main concerns of CUHAS-ROBUST. Nevertheless, this application increases the confidence in decision-making, promotes medical procedure compliance, active surveillance and enhancing a low-cost screening approach.Originality/value>The CUHAS-ROBUST achieved its purpose as a tool for clinical decision-making in RR-TB screening. Moreover, this study demonstrates AI roles in enhancing health-care quality and boost public health efforts against tuberculosis.

What is the impact of SARS-CoV-2 pandemic on antimicrobial stewardship programs (ASPs)? The results of a survey among a regional network of infectious disease centres.

Discontinuation of antimicrobial stewardship programs (ASPs) and increased antibiotic use were described during SARS-CoV-2 pandemic. In order to measure COVID-19 impact on ASPs in a setting of high multidrug resistance organisms (MDRO) prevalence, a qualitative survey was designed. In July 2021, eighteen ID Units were asked to answer a questionnaire about their hospital characteristics, ASPs implementation status before the pandemic and impact of SARS-CoV-2 pandemic on ASPs after the 1st and 2nd pandemic waves in Italy. Nine ID centres (50%) reported a reduction of ASPs and in 7 cases (38.9%) these were suspended. After the early pandemic waves, the proportion of centres that restarted their ASPs was higher among the ID centres where antimicrobial stewardship was formally identified as a priority objective (9/11, 82%, vs 2/7, 28%). SARS-CoV-2 pandemic had a severe impact in ASPs in a region highly affected by COVID-19 and antimicrobial resistance but weaknesses related to the pre-existent ASPs might have played a role.

Risk factors for isolation of carbapenem-resistant Enterobacterales from normally sterile sites and urine.

BACKGROUND: Invasive infections caused by carbapenem-resistant Enterobacterales (CRE) are of significant concern in health care settings. We assessed risk factors for a positive CRE culture from a sterile site (invasive infection) compared to isolation from urine in a large patient cohort in Atlanta from August 2011 to December 2015. METHODS: CRE cases required isolation, from urine or a normally-sterile site, of E. coli, Klebsiella spp., or Enterobacter spp. that were carbapenem-nonsusceptible (excluding ertapenem) and resistant to all third-generation cephalosporins tested. Risk factors were compared between patients with invasive and urinary infections using multivariable logistic regression. RESULTS: A total of 576 patients had at least 1 incident case of CRE, with 91 (16%) having an invasive infection. In multivariable analysis, the presence of a central venous catheter (OR 3.58; 95% CI: 2.06-6.23) or other indwelling device (OR 2.34; 95% CI: 1.35-4.06), and recent surgery within the last year (OR 1.81; 95% CI: 1.08-3.05) were associated with invasive infection when compared to urinary infection. DISCUSSION: Health care exposures and devices were associated with invasive infections in patients with CRE, suggesting that targeting indwelling catheters, including preventing unwarranted insertion or encouraging rapid removal, may be a potential infection control intervention. CONCLUSIONS: Future infection prevention efforts to decrease CRE cases in health care settings should focus on minimizing unnecessary devices.

Alarming Rise in Secondary Infections and Antimicrobial Resistance in COVID-19 Patients Admitted at a Tertiary Care Centre in Dehradun, Northern India

Introduction: Secondary infections are emerging as a serious threat among hospitalised patients of Coronavirus Disease-2019 (COVID-19). Overuse of antibiotics and inadequate infection control practices due to COVID-19 patients' workload leads to a sudden upsurge of Multidrug Resistance (MDR) pathogens in healthcare settings attributing to higher mortality rates among the same. Aim: To detect the secondary infection rate among COVID-19 patients admitted to the hospital ward and Intensive Care Unit (ICU), and report the impact on antimicrobial resistance and patient outcome. Materials and Methods: A retrospective study was conducted for a period of three months of the second COVID-19 wave from 15(th) April 2021 to 14(th) july 2021 in the Department of Microbiology, Himalayan Institute of Medical Sciences (HIMS), Swami Rama Himalayan University (SRHU), Dehradun, Uttarakhand, India. All clinical samples of Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) positive cases of COVID-19 received in the laboratory were cultured and identified using the Vitek-2 automated system and conventional fungal culture. Relevant demographic, characteristics, and clinical outcome data were obtained from records of the patient and recorded in reporting forms and were analysed for the study. Results were analysed with Statistical Package for the Social Sciences (SPSS) version 20.0 and Microsoft Excel 2019. Results: Overall secondary infection rate of 135 (13.6%) was found among COVID-19 admitted patients. The most commonly isolated bacterial pathogens were Coagulase-negative Staphylococcus species (18.52%) and Enterococcus species (8.89%). Whereas the most common fungal isolates were Candida species (20.75%) and Rhizopus (8.15%). In the present study, 60.5% of bacterial pathogens isolated were Multidrug-resistant Organisms (MDRO). Mortality among COVID-19 patients with secondary infection was reported as 53% which was higher than the overall mortality rate of 36% in the same. Conclusion: A high secondary infection rate, MDRO isolation rate, and high mortality among COVID-19 with secondary infection were reported. This shows the urgent need for reinforcement of infection control practices and strict antimicrobial stewardship policies.

Multidrug-resistant OXA-48/CTX-M-15 Klebsiella pneumoniae cluster in a COVID-19 intensive care unit: salient lessons for infection prevention and control during the COVID-19 pandemic.

BACKGROUND: Wards caring for COVID-19 patients, including intensive care units (ICUs), have an important focus on preventing transmission of SARS-CoV-2 to other patients and healthcare workers. AIM: To describe an outbreak of carbapenemase-producing Enterobacterales (CPE) in a COVID-19 ICU and to discuss key infection control measures enabling prompt termination of the cluster. METHODS: CPE were isolated from clinical specimens and screening swabs from intensive care patients with COVID-19 disease and from environmental screening. Whole-genome sequencing analysis was instrumental in informing phylogenetic relationships. FINDINGS: Seven clinical isolates and one environmental carbapenemase-producing Klebsiella pneumoniae isolate - all carrying OXA-48, CTX-M-15 and outer membrane porin mutations in ompK35/ompK36 - were identified with ≤1 single nucleotide polymorphism difference, indicative of clonality. A bundle of infection control interventions including careful adherence with contact precautions and hand hygiene, twice weekly screening for multidrug-resistant organisms, strict antimicrobial stewardship, and enhanced cleaning protocols promptly terminated the outbreak. CONCLUSION: Prolonged use of personal protective equipment is common with donning and doffing stations at the ward entrance, leaving healthcare workers prone to reduced hand hygiene practices between patients. Minimizing transmission of pathogens other than SARS-CoV-2 by careful adherence to normal contact precautions including hand hygiene, even during high patient contact manoeuvres, is critical to prevent outbreaks of multidrug-resistant organisms. Appropriate antimicrobial stewardship and screening for multidrug-resistant organisms must also be maintained throughout surge periods to prevent medium-term escalation in antimicrobial resistance rates. Whole-genome sequencing is highly informative for multidrug-resistant Enterobacterales surveillance strategies.

Bloodstream Infections in a COVID-19 Non-ICU Department: Microbial Epidemiology, Resistance Profiles and Comparative Analysis of Risk Factors and Patients' Outcome.

BACKGROUND: Bloodstream infections (BSI) caused by highly resistant pathogens in non-ICU COVID-19 departments pose important challenges. METHODS: We performed a comparative analysis of incidence and microbial epidemiology of BSI in COVID-19 vs. non-COVID-19, non-ICU departments between 1 September 2020-31 October 2021. Risk factors for BSI and its impact on outcome were evaluated by a case-control study which included COVID-19 patients with/without BSI. RESULTS: Forty out of 1985 COVID-19 patients developed BSI. The mean monthly incidence/100 admissions was 2.015 in COVID-19 and 1.742 in non-COVID-19 departments. Enterococcus and Candida isolates predominated in the COVID-19 group (p < 0.001 and p = 0.018, respectively). All Acinetobacter baumannii isolates were carbapenem-resistant (CR). In the COVID-19 group, 33.3% of Klebsiella pneumoniae was CR, 50% of Escherichia coli produced ESBL and 19% of Enterococcus spp. were VRE vs. 74.5%, 26.1% and 8.8% in the non-COVID-19 group, respectively. BSI was associated with prior hospitalization (p = 0.003), >2 comorbidities (p < 0.001), central venous catheter (p = 0.015), severe SARS-CoV-2 pneumonia and lack of COVID-19 vaccination (p < 0.001). In the multivariate regression model also including age and multiple comorbidities, only BSI was significantly associated with adverse in-hospital outcome [OR (CI95%): 21.47 (3.86-119.21), p < 0.001]. CONCLUSIONS: BSI complicates unvaccinated patients with severe SARS-CoV-2 pneumonia and increases mortality. BSI pathogens and resistance profiles differ among COVID-19/non-COVID-19 departments, suggesting various routes of pathogen acquisition.

A Data-Driven Framework for Identifying Intensive Care Unit Admissions Colonized With Multidrug-Resistant Organisms.

Background: The rising prevalence of multi-drug resistant organisms (MDROs), such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), and Carbapenem-resistant Enterobacteriaceae (CRE), is an increasing concern in healthcare settings. Materials and Methods: Leveraging data from electronic healthcare records and a unique MDRO universal screening program, we developed a data-driven modeling framework to predict MRSA, VRE, and CRE colonization upon intensive care unit (ICU) admission, and identified the associated socio-demographic and clinical factors using logistic regression (LR), random forest (RF), and XGBoost algorithms. We performed threshold optimization for converting predicted probabilities into binary predictions and identified the cut-off maximizing the sum of sensitivity and specificity. Results: Four thousand six hundred seventy ICU admissions (3,958 patients) were examined. MDRO colonization rate was 17.59% (13.03% VRE, 1.45% CRE, and 7.47% MRSA). Our study achieved the following sensitivity and specificity values with the best performing models, respectively: 80% and 66% for VRE with LR, 73% and 77% for CRE with XGBoost, 76% and 59% for MRSA with RF, and 82% and 83% for MDRO (i.e., VRE or CRE or MRSA) with RF. Further, we identified several predictors of MDRO colonization, including long-term care facility stay, current diagnosis of skin/subcutaneous tissue or infectious/parasitic disease, and recent isolation precaution procedures before ICU admission. Conclusion: Our data-driven modeling framework can be used as a clinical decision support tool for timely predictions, characterization and identification of high-risk patients, and selective and timely use of infection control measures in ICUs.

The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature.

BACKGROUND: Despite the adoption of strict infection prevention and control measures, many hospitals have reported outbreaks of multidrug-resistant organisms (MDRO) during the Coronavirus 2019 (COVID-19) pandemic. Following an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in our institution, we sought to systematically analyse characteristics of MDRO outbreaks in times of COVID-19, focussing on contributing factors and specific challenges in controlling these outbreaks. METHODS: We describe results of our own CRAB outbreak investigation and performed a systematic literature review for MDRO (including Candida auris) outbreaks which occurred during the COVID-19 pandemic (between December 2019 and March 2021). Search terms were related to pathogens/resistance mechanisms AND COVID-19. We summarized outbreak characteristics in a narrative synthesis and contrasted contributing factors with implemented control measures. RESULTS: The CRAB outbreak occurred in our intensive care units between September and December 2020 and comprised 10 patients (thereof seven with COVID-19) within two distinct genetic clusters (both ST2 carrying OXA-23). Both clusters presumably originated from COVID-19 patients transferred from the Balkans. Including our outbreak, we identified 17 reports, mostly caused by Candida auris (n = 6) or CRAB (n = 5), with an overall patient mortality of 35% (68/193). All outbreaks involved intensive care settings. Non-adherence to personal protective equipment (PPE) or hand hygiene (n = 11), PPE shortage (n = 8) and high antibiotic use (n = 8) were most commonly reported as contributing factors, followed by environmental contamination (n = 7), prolonged critical illness (n = 7) and lack of trained HCW (n = 7). Implemented measures mainly focussed on PPE/hand hygiene audits (n = 9), environmental cleaning/disinfection (n = 9) and enhanced patient screening (n = 8). Comparing potentially modifiable risk factors and control measures, we found the largest discrepancies in the areas of PPE shortage (risk factor in 8 studies, addressed in 2 studies) and patient overcrowding (risk factor in 5 studies, addressed in 0 studies). CONCLUSIONS: Reported MDRO outbreaks during the COVID-19 pandemic were most often caused by CRAB (including our outbreak) and C. auris. Inadequate PPE/hand hygiene adherence, PPE shortage, and high antibiotic use were the most commonly reported potentially modifiable factors contributing to the outbreaks. These findings should be considered for the prevention of MDRO outbreaks during future COVID-19 waves.

IS IT POSSIBLE TO PREDICT VENTILATOR ASSOCIATED PNEUMONIA ETIOLOGY IN COVID-19 PATIENTS?

COVID-19 infection is no exception and may predispose to secondary bacterial and/or fungal co-infections like COVID-19 Associated Pulmonary Aspergillosis resulting in poor clinical outcomes especially among critically ill patients who require mechanical ventilation. Paolo Gaibani et al. conducted a prospective study (April to May, 2020) in a tertiary hospital in Bologna, Italy to assess the profile of the lower respiratory tract microbiome of critically ill patients with COVID-19 as compared to COVID-19 negative patients by using a 16S rRNA profiling on bronchoalveolar lavage samples. The dysbiosis observed in critically ill patients with COVID-19 was therefore characterized by the reduction of commensal bacterial species and predominance of opportunistic gram-negative pathogens frequently associated with multidrug resistance.

Bacterial Epidemiology and Antimicrobial Resistance Profiles in Children Reported by the ISPED Program in China, 2016 to 2020.

The Infectious Disease Surveillance of Pediatrics (ISPED) program was established in 2015 to monitor and analyze the trends of bacterial epidemiology and antimicrobial resistance (AMR) in children. Clinical bacterial isolates were collected from 11 tertiary care children's hospitals in China in 2016 to 2020. Antimicrobial susceptibility testing was carried out using the Kirby-Bauer method or automated systems, with interpretation according to the Clinical and Laboratory Standards Institute 2019 breakpoints. A total of 288,377 isolates were collected, and the top 10 predominant bacteria were Escherichia coli, Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Acinetobacter baumannii. In 2020, the coronavirus disease 2019 (COVID-19) pandemic year, we observed a significant reduction in the proportion of respiratory tract samples (from 56.9% to 44.0%). A comparable reduction was also seen in the primary bacteria mainly isolated from respiratory tract samples, including S. pneumoniae, H. influenzae, and S. pyogenes. Multidrug-resistant organisms (MDROs) in children were commonly observed and presented higher rates of drug resistance than sensitive strains. The proportions of carbapenem-resistant K. pneumoniae (CRKP), carbapenem-resistant A. baumannii (CRAB), carbapenem-resistant P. aeruginosa (CRPA), and methicillin-resistant S. aureus (MRSA) strains were 19.7%, 46.4%%, 12.8%, and 35.0%, respectively. The proportions of CRKP, CRAB, and CRPA strains all showed decreasing trends between 2015 and 2020. Carbapenem-resistant Enterobacteriaceae (CRE) and CRPA gradually decreased with age, while CRAB showed the opposite trend with age. Both CRE and CRPA pose potential threats to neonates. MDROs show very high levels of AMR and have become an urgent threat to children, suggesting that effective monitoring of AMR and antimicrobial stewardship among children in China are required. IMPORTANCE AMR, especially that involving multidrug-resistant organisms (MDROs), is recognized as a global threat to human health; AMR renders infections increasingly difficult to treat, constituting an enormous economic burden and producing tremendous negative impacts on patient morbidity and mortality rates. There are many surveillance programs in the world to address AMR profiles and MDRO prevalence in humans. However, published studies evaluating the overall AMR rates or MDRO distributions in children are very limited or are of mixed quality. In this study, we showed the bacterial epidemiology and resistance profiles of primary pathogens in Chinese children from 2016 to 2020 for the first time, analyzed MDRO distributions with time and with age, and described MDROs' potential threats to children, especially low-immunity neonates. Our study will be very useful to guide antiinfection therapy in Chinese children, as well as worldwide pediatric patients.

Ventilation-Associated Particulate Matter Is a Potential Reservoir of Multidrug-Resistant Organisms in Health Facilities.

Most healthcare-associated infections (HCAIs) develop due to the colonisation of patients and healthcare workers by multidrug-resistant organisms (MDRO). Here, we investigated whether the particulate matter from the ventilation systems (Vent-PM) of health facilities can harbour MDRO and other microbes, thereby acting as a potential reservoir of HCAIs. Dust samples collected in the ventilation grilles and adjacent air ducts underwent a detailed analysis of physicochemical properties and biodiversity. All Vent-PM samples included ultrafine PM capable of reaching the alveoli. Strikingly, >70% of Vent-PM samples were contaminated, mostly by viruses (>15%) or multidrug-resistant and biofilm-producing bacterial strains (60% and 48% of all bacteria-contaminated specimens, respectively). Total viable count at 1 m from the ventilation grilles was significantly increased after opening doors and windows, indicating an association between air flow and bacterial contamination. Both chemical and microbial compositions of Vent-PM considerably differed across surgical vs. non-surgical and intensive vs. elective care units and between health facilities located in coal and chemical districts. Reduced diversity among MDRO and increased prevalence ratio in multidrug-resistant to the total Enterococcus spp. in Vent-PM testified to the evolving antibiotic resistance. In conclusion, we suggest Vent-PM as a previously underestimated reservoir of HCAI-causing pathogens in the hospital environment.