Nosocomial cluster of carbapenemase-producing Enterobacter cloacae in an intensive care unit dedicated COVID-19.

Concomitant prevention of SARS-CoV-2 and extensively drug-resistant bacteria transmission is a difficult challenge in intensive care units dedicated to COVID-19 patients. We report a nosocomial cluster of four patients carrying NDM-1 plasmid-encoded carbapenemase-producing Enterobacter cloacae. Two main factors may have contributed to cross-transmission: misuse of gloves and absence of change of personal protective equipment, in the context of COVID-19-associated shortage. This work highlights the importance of maintaining infection control measures to prevent CPE cross-transmission despite the difficult context and that this type of outbreak can potentially involve several species of Enterobacterales.

Molecular and epidemiological investigation of a colistin-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii outbreak in the Southwest Indian Ocean Area.

Dual resistance to colistin and carbapenems is a milestone reached by certain extensively-drug resistant (XDR) Gram-negative bacteria. This study describes the first outbreak of XDR colistin- and carbapenem-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii (CCRAB) in the European overseas territory of Reunion Island (France, Indian Ocean). Between April 2019 and June 2020, 13 patients admitted to the University Hospital of Reunion Island were involved in the outbreak, of whom eight were infected and six died. The first case was traced to a medical evacuation from Mayotte Island (Comoros archipelago). An epidemiological link could be established for 11 patients. All of the collected CCRAB isolates showed the same resistance profile and co-produced intrinsic ß-lactamases OXA-69 and ADC-191, together with acquired carbapenem-hydrolysing ß-lactamases OXA-23 and NDM-1. A mutation likely involved in colistin resistance was detected in the two-component system PmrAB (D82N in PmrA). All of the isolates were found to belong to STPas1/STOx231 clonal complex and were phylogenetically indistinguishable. Their further characterization by whole-genome sequence analyses (whole-genome multi-locus sequence typing, single nucleotide polymorphisms) provided hints about the transmission pathways. This study pleads for strict application of control and prevention measures in institutions where the risk of imported XDR bacteria is high.

Case Report: Emergence of Candida auris in the Indian Ocean Region.

Candida auris is an emerging multidrug-resistant yeast that can cause severe infections and spread easily between hospitalized patients, leading to outbreaks in hospital. Here, we report the first four cases of colonization and invasive infection with C. auris reported in the Indian Ocean region. All cases were observed in the French overseas Reunion Island, a very popular destination for European travelers. Three patients had urinary tract or skin colonization, and one had a fatal invasive infection. In three cases, including that of the infected patient, the yeast was not initially identified as C. auris, preventing specific hygiene measures to be implemented as suggested in the December 2016 clinical alert to European healthcare facilities. The infected patient likely acquired C. auris in the intensive care unit from the first colonized patient. This is the first case of C. auris infection and the first potential case of nosocomial transmission of the pathogen to be reported in the French overseas Reunion Island.

Reunion Island, a sentinel territory for antimicrobial-resistant bacteria surveillance in the South-Western Indian Ocean: a retrospective survey using hospitalized patient screening, 2015-2017.

BACKGROUND: In 2015, antimicrobial resistance was identified as a public health priority for the South-Western Indian Ocean (SWIO) (i.e. Comoros, Madagascar, Mauritius, Mayotte (France), Reunion Island (France), and Seychelles). However, in 2020, colonization rates of antimicrobial-resistant bacteria (ARB) in human populations on most islands in SWIO were still not known and neither hospital nor community colonization rates had been estimated. The aim of this study was to estimate the prevalence of colonization of six ARB groups in hospitalized patients residing in the SWIO territories. The six groups comprise extended-spectrum betalactamase producing Enterobacteriaceae (ESBL-E), carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and both ceftazidime and/or imipenem-resistant Acinetobacter spp. (ACB), and ceftazidime and/or imipenem-resistant Pseudomonas spp. (PSA)). METHODS: Based on comprehensive hospital laboratory ARB screening data, we provide the first estimation of ARB colonization rates in hospitalized patients residing in SWIO (2015-2017). Using ARB colonization rates in Reunion Island (France) as the reference for estimating odds ratio, we identified at risk patients based on their territory of residence. RESULTS: The survey pointed to significantly higher overall ARB colonization rates in patients from Comoros, Madagascar, Mayotte, and Seychelles compared to Reunion Island as the reference. Extended-spectrum betalactamase producing Enterobacteriaceae was found to be the most common ARB group colonizing patients from SWIO territories. The highest MRSA colonization rates were observed in patients from Mayotte and Seychelles. Colonization by carbapenem-resistant Enterobacteriaceae (CRE) was highest in patients from Mauritius. CONCLUSION: These results identify high ARB colonization rates in hospitalized patients from SWIO territories that require further investigation, particularly CRE in Mauritius and MRSA in Seychelles and Mayotte. This study is the first step toward the implementation of a broader regional ARB surveillance system.

Carbapenemase-producing Enterobacteriaceae circulating in the Reunion Island, a French territory in the Southwest Indian Ocean.

BACKGROUND: The spread of carbapenemase-producing Enterobacteriaceae (CPE) in the Southwest Indian Ocean area (SIOA) is poorly documented. Reunion Island is a French overseas territory located close to Madagascar and connected with Southern Africa, Indian sub-continent and Europe, with several weekly flights. Here we report the results of the CPE surveillance program in Reunion Island over a six-year period. METHODS: All CPE were collected between January 2011 and December 2016. Demographics and clinical data of the carrier patients were collected. We determined their susceptibility to antimicrobials, identified the carbapenemases and ESBL by PCR and sequencing, and explored their genetic relationship using pulsed-field gel electrophoresis and multi-locus sequence typing. RESULTS: A total of 61 CPEs isolated from 53 patients were retrieved in 6 public or private laboratories of the island. We found that 69.8% of CPE patients were linked to a foreign country of SIOA and that almost half of CPE cases (47.2%) reached the island through a medical evacuation. The annual number of CPE cases strongly increased over the studied period (one case in 2011 vs. 21 cases in 2016). A proportion of 17.5% of CPE isolates were non-susceptible to colistin. blaNDM was the most frequent carbapenemase (79.4%), followed by blaIMI (11.1%), and blaIMP-10 (4.8%). Autochtonous CPE cases (30.2%) harboured CPE isolates belonging to a polyclonal population. CONCLUSIONS: Because the hospital of Reunion Island is the only reference healthcare setting of the SIOA, we can reasonably estimate that its CPE epidemiology reflects that of this area. Mauritius was the main provider of foreign CPE cases (35.5%). We also showed that autochthonous isolates of CPEs are mostly polyclonal, thus unrelated to cross-transmission. This demonstrates the local spread of carbapenemase-encoding genes (i.e. blaNDM) in a polyclonal bacterial population and raises fears that Reunion Island could contribute to the influx of NDM-carbapenemase producers into the French mainland territory.

Derivation and validation of a simple score to predict the presence of bacteria requiring carbapenem treatment in ICU-acquired bloodstream infection and pneumonia: CarbaSCORE.

Background: The recommendations of learned societies mention risk factors for the presence of multidrug resistant bacteria in hospital-acquired infections, but they do not propose a scoring system to guide empiric antibiotic therapy. Our study was aimed at developing a simple score for predicting "the presence of bacteria requiring carbapenem treatment" in ICU-acquired bloodstream infection and pneumonia. Methods: Between December 2011 and January 2015, we conducted a retrospective study using a prospectively collected French database of nosocomial infections in the polyvalent intensive care unit of a French university hospital. All patients with ICU-acquired bloodstream infection or pneumonia were included in the study. Bivariate and multivariate analyses were performed to develop the CarbaSCORE, and this score was internally validated. Results: In total, 338 patients were analyzed, including 27 patients requiring carbapenem treatment. The CarbaSCORE was composed of four criteria: "presence of bloodstream infection" (as opposed to pneumonia) scored 2 points, "chronic hemodialysis" scored 4 points, "travel abroad in the last 6 months" scored 5 points, and "MDR-colonization or prior use of a ß-lactam of class ≥ 3" scored 6 points. Internal validation by bootstrapping showed an area under the receiver operating characteristic curve of 0.81 [0.73-0.89]. Sensitivity was 96% at the 6-point threshold and specificity was 91% at the 9-point threshold. Conclusions: The CarbaSCORE is a simple and efficient score for predicting the presence of bacteria requiring carbapenem treatment. Further studies are needed to test this score before it can be used in practice.

Cannula-Related Infection in Patients Supported by Peripheral ECMO: Clinical and Microbiological Characteristics.

Little is known about cannula-related infection (CRI) in patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to assess the incidence, the risk factors, prognosis, and microbiological characteristics of CRI in patients supported by ECMO. This retrospective cohort study was conducted in one intensive care unit (ICU). Among 220 consecutive patients with peripheral ECMO, 39 (17.7%) developed CRI. The incidence of CRI was 17.2 per 1,000 ECMO days. The main isolated microorganisms were Enterobacteriaceae (38%), Staphylococcus spp. (28.2%; 8.5% were methicillin-sensitive Staphylococcus aureus and 19.7% were coagulase-negative staphylococci), and Pseudomonas aeruginosa (18.3%). Bacteremia was present in 23 cases (59.7%). In multivariate analysis, the risk factors for CRI were longer ECMO duration (p = 0.006) and higher Simplified Acute Physiology Score 2 (p = 0.004). Forty-one percentage of patients with CRI needed surgical management of the infected site. Cannula-related infection was not associated with higher in-hospital mortality (p = 0.73), but it was associated with a longer stay in ICU (p < 0.0001) and a longer stay in hospital (p = 0.002). In conclusion, CRI is frequent in patients with ECMO and associated with a longer stay in hospital. Risk factors for CRI were longer ECMO duration and higher Simplified Acute Physiology Score 2. Concomitant bacteremia was frequent (59.7%) and CRI should be strongly investigated in cases of positive blood culture.

Outbreak of IMI-1 carbapenemase-producing colistin-resistant Enterobacter cloacae on the French island of Mayotte (Indian Ocean).

The spread of carbapenemase-producing Enterobacteriaceae in the Southwest Indian Ocean islands is poorly known. Here we describe an outbreak of colistin-resistant Enterobacter cloacae harbouring blaIMI-1 in the French overseas department of Mayotte. Between October 2015 and January 2017, all isolates of imipenem-non-susceptible E. cloacae at Mayotte Medical Center and University Hospital of Reunion Island were screened for carbapenemase production. Positive isolates were typed by pulsed-field gel electrophoresis and whole-genome sequencing (WGS)-based multilocus sequence typing (MLST), and all ß-lactamase genes were identified by PCR and sequencing. Resistance profiles were determined by agar diffusion and Etest. Genetic support of the blaIMI-1 gene was determined by WGS. A total of 18 E. cloacae isolates harbouring blaIMI-1 were detected in 17 patients from Mayotte. Pulsed-field gel electrophoresis (PFGE) analysis showed 16 of the 18 strains to be clonally related and belonging to ST820. Based on clinical data, this outbreak most likely had a community origin. The blaIMI-1 gene in the 18 isolates was carried by a new variant of an integrative mobile element involving the Xer recombinases, called EcloIMEX-8. The mcr-1-mcr-5 genes were absent from the collection. The isolates belonged to E. cloacae cluster XI, known to be colistin heteroresistant. Here we report the first outbreak of IMI-1-producing Enterobacteriaceae. IMI-1-producers may be underdetected in microbiology laboratories because of their unusual antimicrobial resistance profile (resistant to imipenem but with intermediate resistance to ertapenem and susceptible to extended-spectrum cephalosporins) and the absence of blaIMI-1 in the panel of genes targeted by molecular diagnostic kits.

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad.

BACKGROUND: Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients. METHODS: In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission. RESULTS: Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor. CONCLUSIONS: The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening.

Delayed diagnosis of high drug-resistant microorganisms carriage in repatriated patients: three cases in a French intensive care unit.

We report three cases of high drug-resistant microorganisms (HDRMO) carriage by patients repatriated from a foreign country. National recommendations suggest systematic screening and contact isolation pending results of admission screening of all patients recently hospitalized abroad. HDRMO carriage (carbapenem-resistant Acinetobacter baumanii and carbapenemase-producing Enterobacteriaceae) was not isolated on admission screening swabs, but later between 3 and 8 days after admission. In absence of cross-transmission, two hypotheses seem possible: a false-negative test on admission, or a late onset favored by antibiotic pressure. Prolonged isolation may be discussed even in case of negative screening on admission from high-risk patients.