Epidemiology and outcomes of vancomycin-resistant enterococcus infections: a systematic review and meta-analysis.

Vancomycin-resistant enterococci (VRE) cause many infections in the healthcare context. Knowledge regarding the epidemiology and burden of VRE infections, however, remains fragmented. We aimed to summarize recent studies on VRE epidemiology and outcomes in hospitals, long-term-care facilities (LTCFs) and nursing homes worldwide based on current epidemiological reports. We searched MEDLINE/PubMed, the Cochrane Library, and Web of Science for observational studies, which reported on VRE faecium and faecalis infections in in-patients published between January 2014 and December 2020. Outcomes were incidence, infection rate, mortality, length of stay (LOS), and healthcare costs. We conducted a meta-analysis on mortality (PROSPERO registration number: CRD42020146389). Of 681 identified publications, 57 studies were included in the analysis. Overall quality of evidence was moderate to low. VRE incidence was rarely and heterogeneously reported. VRE infection rate differed highly (1-55%). The meta-analysis showed a higher mortality for VRE faecium bloodstream infections (BSIs) compared with VSE faecium BSIs (risk ratio, RR 1.46; 95% confidence interval (CI) 1.17-1.82). No difference was observed when comparing VRE faecium vs VRE faecalis BSI (RR 1.00, 95% CI 0.52-1.93). LOS was higher in BSIs caused by E. faecium vs E. faecalis. Only three studies reported healthcare costs. In contrast to previous findings, our meta-analysis of included studies indicates that vancomycin resistance independent of VRE species may be associated with a higher mortality. We identified a lack of standardization in reporting outcomes, information regarding healthcare costs, and state-of-the-art microbiological species identification methodology, which may inform the set-up and reporting of future studies.

Impact of discontinuing contact precautions and enforcement of basic hygiene measures on nosocomial vancomycin-resistant Enterococcus faecium transmission.

OBJECTIVES: Vancomycin-resistant Enterococcus faecium (VREfm) has emerged as a pathogen of major concern for public health. Although definitive evidence is lacking, contact precautions have been a crucial element in infection prevention and control (IPC) strategies designed to limit nosocomial VRE transmission. This study investigated the effect of discontinuing contact precautions while enforcing basic hygiene measures, including hand hygiene, environmental cleaning and antiseptic body washing, for patients with VRE in intensive care units (ICUs) on the prevention of nosocomial VRE transmission causing bacteraemia. METHODS: Contact precautions were discontinued in January 2018. In total, 96 VREfm isolates from 61 patients with VREfm bacteraemia and/or colonization hospitalized in eight ICUs in a tertiary care hospital in 2016 and 2019 in were characterized by whole-genome sequencing. VRE transmission was investigated using patient movement data and admission screening for reliable identification of nosocomial acquisition. RESULTS: Discontinuation of contact precautions did not increase VREfm transmission events (eight in 2016 vs one in 2019). While the rate of endogenous VREfm was similar in both years (38% vs 31%), the number of non-colonized patients prior to VREfm bacteraemia was 16 (16/29, 55%) in 2019, which was significantly higher than in 2016 (8/32, 25%). The mean incidence density for VREfm bacteraemia was similar for both years (0.26 vs 0.31 per 1000 patient-days in 2016 and 2019, respectively). CONCLUSION: Discontinuation of contact precautions while enforcing basic hygiene measures did not lead to an increase in nosocomial bloodstream infection rates due to VREfm transmission in a hyperendemic ICU setting.

In Search of Patient Zero: Visual Analytics of Pathogen Transmission Pathways in Hospitals.

Pathogen outbreaks (i.e., outbreaks of bacteria and viruses) in hospitals can cause high mortality rates and increase costs for hospitals significantly. An outbreak is generally noticed when the number of infected patients rises above an endemic level or the usual prevalence of a pathogen in a defined population. Reconstructing transmission pathways back to the source of an outbreak - the patient zero or index patient - requires the analysis of microbiological data and patient contacts. This is often manually completed by infection control experts. We present a novel visual analytics approach to support the analysis of transmission pathways, patient contacts, the progression of the outbreak, and patient timelines during hospitalization. Infection control experts applied our solution to a real outbreak of Klebsiella pneumoniae in a large German hospital. Using our system, our experts were able to scale the analysis of transmission pathways to longer time intervals (i.e., several years of data instead of days) and across a larger number of wards. Also, the system is able to reduce the analysis time from days to hours. In our final study, feedback from twenty-five experts from seven German hospitals provides evidence that our solution brings significant benefits for analyzing outbreaks.

Alteration of antibiotic regimen as an additional control measure in suspected multi-drug-resistant Enterobacter cloacae outbreak in a neonatal intensive care unit.

BACKGROUND: Increased occurrence of a particular species of Gram-negative bacteria (GNB), especially when multi-drug-resistant (MDR), in routine screening surveillance in neonatal intensive care units (NICUs) can be evoked by selection pressure. AIM: To evaluate adaptation of the empiric antibiotic regimen for its usefulness as a control measure in suspected outbreaks in the NICU. METHODS: In a retrospective outbreak analysis, cases between 1st December 2017 and 31st March 2018 were identified through microbiology and hygiene surveillance records. Furthermore, risk factors for MDR-GNB colonization were collected. Whole-genome sequencing (WGS) was performed on all isolates. Control measure documentations and interviews were employed to define interventions. As well as infection control measures, administration of third-generation cephalosporins was avoided and replaced whenever clinically acceptable as part of the intervention bundle. FINDINGS: In total, nine patients were found to have rectal colonization with third-generation cephalosporin-resistant Enterobacter cloacae in routine screening surveillance in the pre-intervention period. After implementation of an infection control bundle, the incidence declined rapidly. WGS analysis revealed that two MDR E. cloacae were transmitted, and the majority were new cases. The incidence density of MDR-GNB colonization was 7.94/1000 patient-days (PD) before the intervention and 1.68/1000 PD during the altered antibiotic regimen. No infections with MDR-GNB occurred during the study. CONCLUSIONS: Altering the antibiotic regimen with regard to selection pressure may be considered as part of an intervention bundle to rapidly control the emergence of MDR-GNB in suspected outbreak situations in the NICU.

Wishes and expectations of pregnant women and their partners concerning delivery.

AIMS: The study investigated factors related to the expectations and wishes concerning delivery of expectant parents. METHODS: A self-administered questionnaire on the relevant aspects of delivery was developed, pre-tested, and administered to 545 expectant mothers (n = 336) and fathers (n = 209) attending open house informational events at 3 hospitals around Giessen, Germany. RESULTS: Response rate was 96.3%. Three major areas of interest were identified and converted into scales: "management and obstetrical equipment" (ME; alpha = 0.81), "medical standards" (MS; alpha = 0.82), and "hospital conveniences" (HC; alpha = 0.78). Preferences of participants were influenced by age, gender and parity, as well as by different levels of state- and trait-anxiety. Expectant fathers focused more on HC of the hospital whereas ME, as well as MS, were more important to pregnant women, especially older women from rural areas with high state and/or trait anxiety (p < or = 0.05). However, MS were also found to be important for younger, nulliparous women with at risk pregnancy. Parents of high-risk pregnancies did not emphasize their wishes for ME (p < or = 0.05). CONCLUSION: Fashionable obstetrical equipment of delivery rooms, high medical standards, the reputation of the hospital, and certain conveniences are important issues for expectant parents. However, their importance varies with the above mentioned factors.

[Comparative studies of diagnostically significant enzymes in plasma, udder lymph and milk of healthy cows and cows with udder diseases]. / Vergleichende Untersuchungen diagnostisch bedeutsamer Enzyme in Blutplasma, Euterlymphe und Milch von gesunden und euterkranken Kühen.

Different secretions (colostrum, milk, dry udder secretion) of every quarter, peripheral lymph from superficial lymph vessels of the mammary gland and blood from the V. epigastrica superficialis were obtained in 43 cows at different stages of lactation. In these samples the activity of 5 enzymes (LDH, NAG, AP, LAP, GGT) was determined. Levels of LDH and NAG were highest in blood plasma and udder lymph. Levels of LAP, AP and GGT were highest in milk increasing in this order. LDH, NAG, AP and LAP were correlated in both compartments. Changes of the functional state (dry or colostral period) and tissue disturbances of the mammary gland were accompanied by marked changes of enzyme activity in the secretions, but were without obvious influence on enzyme levels in blood plasma and udder lymph.

[Determination of leucine aminopeptidase in cow's milk]. / Untersuchungen zur Bestimmung der Leuzinaminopeptidase in der Kuhmilch.

Reported in this paper are studies into the applicability of the Fermognost LAP test set (VEB Arzneimittelwerke Dresden) to the measurement of leucine-aminopeptidase activity (LAP) in milk and blood serum of cows. Testing of optimum measuring conditions under which to use the enzyme assay method in milk checks revealed that the LAP test set can be used for LAP activity measurement of milk and blood serum of cows, provided proper preparation of the milk and due consideration of other testing approaches. Colorimetric measurement is made in cuvettes, with 0.1 cm in layer thickness. Dilution or storage of milk samples is not permissible, since changes in enzyme activity are of incidental nature. LAP activities between 4 U/l and 150 U/l were recorded from 280 milk samples. Variation recorded for milk from clinically intact udder quarters was between 4 U/l and 35 U/l, as established by comparison of various parameters, such as cell count, chloride, and lactose. An upper limit value of 40 U/l was derived from that variation. Reproducibility of that enzyme assay method for milk was V = 2.8 per cent, S = +/-0.7 U/l. The milk enzyme was inhibited by chelate formers and activated by Mn2+ ions. LAP activities between 5 U/l and 37 U/l were recorded from 28 blood sera of cattle and gave a mean value of 14 U/l. No regular relationship was found to exist between LAP activities in milk from various udders, and in blood serum of cattle.