Antimicrobial Resistance and Infection Control最新文献

Background: This work aims at providing practical recommendations for implementing automated surveillance (AS) of surgical site infections (SSI) in hospitals and surveillance networks. It also provides an overview of the steps, choices, and obstacles that need to be taken into consideration when implementing such surveillance. Hands-on experience with existing automated surveillance systems of SSI (AS SSI systems) in Denmark, France, the Netherlands and Spain is described regarding trend monitoring, benchmarking, quality control, and research for surveillance purposes.

Methods: Between April and October 2023, specific aspects/options of various surveillance purposes for AS SSI were identified during regular meetings of the SSI working group in the PRAISE (Providing a Roadmap for Automated Infection Surveillance in Europe) network. Expert discussions provided the basis for this perspective article.

Results: Decisions for implementation of AS SSI systems highly depend on the purpose of the surveillance. AS SSI systems presented here differ according to study population, setting, central or local implementation; the level of automation, design, and the data sources used. However, similarities were found for the rationales of automation, design principles and obstacles that were identified. There was consensus among all the experts that shortcomings in interoperability of databases, limited time, a want of commitment on the part of stakeholders, and a shortage of resources for information technology (IT) specialists represent the main obstacles for implementing AS SSI. To overcome obstacles, various solutions were reported, including training in the development of AS systems and the interpretation of AS SSI results, early consultation of end-users, and regular exchanges between management levels, IT departments, infection prevention and control (IPC) teams, and clinicians.

Conclusion: Clarity on the intended application (e.g. purpose of surveillance) and information on the availability of electronic and structured data are crucial first steps necessary for guiding decisions on the design of AS systems. Adequate resources for IT specialists and regular communication between management, IT departments, IPC teams, and clinicians were identified as essential for successful implementation. This perspective article may be helpful for a wider implementation of more homogeneous AS SSI systems in Europe.

Background: Hand hygiene is a critical component of infection prevention in healthcare settings. Innovative strategies are required to enhance hand hygiene practices among patients and healthcare workers (HCWs).

Methods: This study was conducted at the Chemotherapy Day Center of Queen Mary Hospital, Hong Kong. It comprised three phases: phase 1 involved observational audits of hand hygiene practices among patients and HCWs by infection control nurse (ICN); phase 2 included the installation of 53 pressure sensors on alcohol-based hand rub (AHR) bottles at designated sites to monitor usage; phase 3 introduced the robot named Temi Medic to promote hand hygiene through video broadcasts at strategic locations in the center. The mean counts of pressure sensor-equipped AHR per 100 attendances per day (hereafter referred to as the mean count) across phases 2 and 3 were analyzed.

Results: A total of 2580 patient attended the center from April to September 2023. The ICN observed a significant increase in hand hygiene practices among patients at the entrance and reception area, rising from phase 1 (0.2%, 1/583) and phase 2 (0.5%, 3/656) to phase 3 (5.0%, 33/654) (p < 0.001). Meanwhile, the overall hand hygiene compliance among HCWs was 74.1% (1341/1810) throughout the study period. From phase 2 to phase 3, the mean counts of 7 AHR bottles designated for patient use (P1-P7) significantly increased (35 ± 17 vs. 64 ± 24, p < 0.001), as did the 33 AHR bottles shared by both patients and HCWs (207 ± 104 vs. 267 ± 113, p = 0.027). In contrast, there was no significant change in the mean count among the 13 AHR bottles designated for HCWs (H1-H13). The mean count of H1-H13 was significantly higher than that of P1-P7 throughout phases 2 and 3 (214 ± 93 vs. 49 ± 25, p < 0.001), indicating a 4.4-fold difference.

Conclusions: While HCWs maintained stable hand hygiene compliance, the introduction of the robot significantly improved hand hygiene practices among patients in the chemotherapy day center. This underscores the importance of integrating technology into routine practices to promote infection prevention and control in healthcare settings.

Background: Active screening programs and early detection of asymptomatic carriers are effective in preventing carbapenem-resistant Acinetobacter baumannii (CRAB) dissemination in healthcare facilities. This study aims to identify risk factors associated with CRAB carriage among patients upon admission to an acute care hospital.

Methods: A case-case-control study was conducted at an acute care hospital. Starting in June 2020, new admissions to medical wards underwent rectal and buccal screening. Patients with CRAB or carbapenem-susceptible A. baumannii (CSAB) carriage were compared to controls, randomly selected from patients with negative cultures, at a one-to-one ratio. Multinomial logistic regression using a backward stepwise method was employed to identify factors associated with CRAB and CSAB carriage. A Chi-square Automatic Interaction Detector analysis was also conducted to further elucidate risk factors.

Results: The study included 115 CRAB carriers, 117 CSAB carriers and 121 controls. Increasing age was associated with a reduced risk of CSAB (OR: 0.96, p < 0.001) and CRAB carriage (OR: 0.97, p = 0.02), while higher Charlson Comorbidity Index scores increased the risk for both. CRAB carriage was significantly associated with admission from long-term acute care hospitals (OR: 7.68, p < 0.001) and presence of pressure ulcers (OR: 89.98, p < 0.001). Decision tree analysis identified pressure ulcers, prior location, and Charlson score as key predictors, with CRAB carriage reaching 77.3% in patients admitted from long-term acute care hospitals with pressure ulcers.

Conclusion: Pressure ulcers were strongly associated with the carriage of both susceptible and resistant strains of A. baumannii. CRAB carriage was predominantly observed in patients transferred from long-term acute care hospitals, highlighting the need for targeted screening in this high-risk population.

Background: As part of the containment of the COVID-19 pandemic, mobile handwashing stations (mHWS) were deployed in healthcare facilities in low-resource settings. We assessed mHWS in hospitals in the Democratic Republic of the Congo for contamination with Gram-negative bacteria.

Methods: Water and soap samples of in-use mHWS in hospitals in Kinshasa and Lubumbashi were quantitatively cultured for Gram-negative bacteria which were tested for antibiotic susceptibility. Meropenem resistant isolates were assessed for carbapenemase enzymes using inhibitor-based disk and immunochromatographic tests. Mobile handwashing stations that grew Gram-negative bacteria at counts > 10,000 colony forming units/ml from water or soap were defined as highly contaminated.

Results: In 26 hospitals, 281 mHWS were sampled; 92.5% had the "bucket with hand-operated tap" design, 50.5% had soap available. Overall, 70.5% of mHWS grew Gram-negative bacteria; 35.2% (in 21/26 hospitals) were highly contaminated. Isolates from water samples (n = 420) comprised 50.3% Enterobacterales (Klebsiella spp., Citrobacter freundii, Enterobacter cloacae), 14.8% Pseudomonas aeruginosa and 35.0% other non-fermentative Gram-negative bacteria (NFGNB, including Chromobacterium violaceum and Acinetobacter baumannii). Isolates from soap samples (n = 56) comprised Enterobacterales (67.9%, including Pluralibacter gergoviae (n = 13)); P. aeruginosa (n = 12) and other NFGNB (n = 6). Nearly one-third (31.2%, 73/234) of Enterobacterales (water and soap isolates combined) were multi-drug resistant; 13 isolates (5.5%) were meropenem-resistant including 10 New Delhi metallo-beta-lactamase (NDM) producers. Among P. aeruginosa and the other NFGNB, 7/198 (3.5%) isolates were meropenem resistant, 2 were NDM producers. Bacteria listed as critical or high priority on the World Health Organization Bacterial Priority Pathogens List accounted for 20.3% of isolates and were present in 12.0% of all mHWS across 13/26 hospitals. Half (50.5%) of highly contaminated mHWS were used by healthcare workers and patients as well as by caretakers and visitors.

Conclusions: More than one third of in-use mobile handwash stations in healthcare facilities in a low resource setting were highly contaminated with clinically relevant bacteria, part of which were multidrug resistant. The findings urge a rethink of the place of mobile handwash stations in healthcare facilities and to consider measures to prevent their contamination.

Background: Recognition of carbapenem-resistant gram-negative bacteria (CR-GNB) carriage is frequently delayed, which increases the risk of subsequent infection and transmission. Previously, we developed a scoring system to identify CR-GNB carriage upon intensive care unit (ICU) admission. Although the ICU-CARB score showed satisfactory performance, it has not been externally validated. In this study, therefore, we externally validated the ICU-CARB score.

Methods: In the previous article, we introduced a risk-scoring system that incorporated seven key variables: neurological disease, high-risk department history, length of stay ≥ 14 days, ICU history, invasive mechanical ventilation, gastrointestinal tube placement, and carbapenem usage. To externally validate the ICU-CARB score, we conducted a study involving patients admitted to the ICUs of four tertiary hospitals between January 2021 and December 2023. Patients from three hospitals were grouped into Cohort I (n = 815) and those from the fourth hospital into Cohort II (n = 1602). Model calibration, discrimination, and performance were then assessed.

Results: A total of 2417 patients were included, among which 289 (12%) carried CR-GNB upon ICU admission. Neurological disease, high-risk department history and length of stay ≥ 14 days were still 3 most important contributing factors in the scoring system. The ICU-CARB score exhibited high calibration, with an area under the receiver operating characteristic curve of 0.825 (95% confidence interval [CI], 0.778-0.873) for Cohort I and 0.823 (95% CI, 0.791-0.855) for Cohort II. The ICU-CARB score showed a highly positive association with CR-GNB carriage in both cohort I (C = 0.315; P < 0.001) and Cohort II (C = 0.381; P < 0.001).

Conclusions: Despite differences in patient population characteristics, the ICU-CARB score for CR-GNB carriage upon ICU admission exhibited good discrimination in external validation, supporting its potential generalizability to other ICU settings.

Background: The necessity of post procedural prophylactic antibiotics following clean surgeries is controversial. While most evidence suggests that there is no benefit from these additional antibiotics and guidelines do not support their use, there is a paucity of evidence as to how often they are still being used and their impact on infection outcomes. The current study assessed the use of prophylactic antibiotics following cardiac implantable electronic device (CIED) implantations in the province of Alberta, and their impact on infection and mortality.

Methods: We conducted a population-based cohort study in the province of Alberta. Administrative data was used to link all patients ≥ 18 who underwent outpatient CIED implantation from January 1, 2011 through December 31, 2019 to antibiotics commonly used for surgical prophylaxis which were prescribed within 48 h of implantation. The primary outcome, explored with an adjusted Poisson model, was incidence of complex surgical site infection within one year of device implantation. All-cause mortality was a secondary outcome.

Results: Post implantation prophylactic antibiotics were used 41% of the time overall, though the rate has been decreasing over time. The most commonly used prophylactic antibiotic was cefalexin (52%). When adjusted analyses were completed, there was no difference in the outcome of infection between those who did and did not receive post implantation prophylactic antibiotics (Relative Risk 0.74, 95% CI 0.46-1.17) and there was no difference in mortality (Relative Risk 0.8, 95% CI 0.63-1.02).

Conclusions: The use of prophylactic antibiotics following CIED implantation does not correlate to a reduced rate of complex surgical site infection or reduced mortality. The widespread use of these antibiotics, which is not guideline concordant, suggests the need for targeted antimicrobial stewardship interventions for surgical prophylaxis to ensure that antibiotic use is being optimized. Further work should explore other adverse outcomes associated with this antibiotic usage and stewardship programs should explore interventions to educate and reduce antibiotic use for this indication.

Background: Congestive heart failure has reached pandemic levels, and left-ventricular assist devices (LVAD) are increasingly used to treat refractory heart failure. Infection is a leading complication of LVADs. Despite numerous reports (most being retrospective), several knowledge gaps pertaining to the epidemiology and burden of an LVAD-associated infection (LVADi) remain. We sought to address these gaps using a prospective, case-control design.

Methods: All patients who received an LVAD from November 1, 2018 to August 31, 2023 (n = 110) were included and prospectively monitored until death. Data were extracted from clinical encounters and medical records in real-time or near real-time and imported to Excel and REDcap electronic data capture tools. An LVADi was ascertained using definitions from the mechanical circulatory support academic research consortium in conjunction with and the U.S. National Health Safety Network. All meeting those definitions were included as 'cases.' Patients with no LVADi were controls. Excess lengths-of-stays (LOS) and direct costs were calculated from billing records using a commercial cost accounting software platform (Strata^®, Chicago, IL).

Results: The amount of healthcare contact before implantation and discharge to a rehabilitation or skilled nursing facility instead of home were the primary risks for infection, resulting in mean excesses of 25 hospital and 60 antibiotic-days and $43,000 per event. One-third occurred > 1 year after implantation. 35% developed > 1 infection. Gram-negative, fungal, and antimicrobial-resistant organisms predominated deep or repeat infections. 7.2% developed ≥ 3 infections. Organisms became increasingly antimicrobial resistant with subsequent infections, leading to extensive or pan-drug resistance in 4.5% of patients. The burden of an LVADi was 1862 excess hospital days, 3960 excess antibiotic days, and $3.4 million.

Conclusions: Patients with LVADis had significant increases in costs, LOS, readmissions, and antibiotic usage. Antimicrobial resistance varied directly with the number of repeat infections and antibiotic exposure. Identification of factors associated with LVADi, and quantification of the burden of LVADi can inform prevention efforts and lead to reduced infection rates. As preventing infections in the first place is also important for limiting the emergence of antimicrobial resistance, we offer strategies to avoid LVADis.

Trial registry: Not applicable.

Background: The emergence and spread of Extended-Spectrum Beta-Lactamase (ESBL)-producing Escherichia coli pose significant challenges for treatment of infections globally. This challenge is exacerbated in sub-Saharan African countries, where the prevalence of ESBL-producing E. coli is high. This, combined with the lack of a strong and supportive healthcare system, leads to increased morbidity and mortality due to treatment failures. Notably, studies in Ethiopia have primarily focused on hospital settings, leaving a gap in understanding ESBL prevalence in rural communities, where human-animal proximity may facilitate microbial exchange.

Methods: We conducted a community-based study in the rural Somali region of Ethiopia, simultaneously examining the fecal carriage of ESBL-producing E. coli in children aged 2-5 years and their livestock (cattle, camel, goat). Fecal samples from 366 children and 243 animals underwent phenotypic screening for ESBL-producing E. coli. Following phenotypic confirmation, ESBL resistance genes were identified via conventional PCR. Whole-genome sequencing (WGS) was performed on a subset of isolates from human feces.

Results: We found that 43% (159/366) of children and 3.7% (9/244) of livestock harbored ESBL-producing E. coli. The ESBL gene bla_CTX-M-15 was predominant in human (82.7%, 120/145) and livestock (100%) isolates. In the 48 human E. coli isolates subjected to WGS, a high diversity resulting in 40 sequence types (STs) was observed. Among these, ST-2353 was the most prevalent (5/48), followed by ST-10 and ST-48 (3/48) and ST-38, ST-450, and ST-4750 (2/48). These STs were associated with multiple resistance genes, such as bla_CTX-M-15, bla_TEM-1B, bla_OXA-1, bla_CTX-M-14 and bla_TEM-35.

Conclusion: We report a high prevalence of ESBL E. coli in rural children, which outnumbers its prevalence in livestock. These isolates displayed a high diversity of sequence types (STs) with ST-2353 being the dominant ST. Our study is the first to report the association of ST-2353 with multi-drug resistance genes in Ethiopia. Further research using an integrated approach including other domains such as water and food products is needed to truly understand and combat AMR transmission and acquisition in this region.

Background: The Caribbean lacks recent comprehensive antimicrobial resistance data to inform clinicians and decision-makers. This study aims to provide a snapshot of susceptibility trends for pathogens on Curaçao, an island in the southern Caribbean.

Methods: We analyzed susceptibility data of bacterial pathogens isolated from samples submitted from patients attending general practitioners, outpatient clinics and those who were hospitalized between January 2018 and December 2023. Samples originating from blood, urine, genital tract, soft tissue, and lungs were included. Susceptibility testing was performed by VITEK2 according using the European Committee on Antimicrobial Susceptibility Testing criteria.

Results: In total, 13,528 patients contributed to 22,876 first isolates. Of all infections in adults with Staphylococcus aureus, 14% (95% confidence interval 10-18%) were methicillin-resistant S. aureus (MRSA) in blood, and up to 27% (20-35%) in soft-tissue cultures. For Escherichia coli and Klebsiella pneumoniae, resistance levels were up to 27% (95% CI 22-32%) for cefuroxime and up to 18% (95% CI 18-28%) for third-generation cephalosporins. The addition of gentamicin to empirical therapy with cefuroxime increased coverage only moderately, especially in K. pneumoniae (16%, 95% CI 12-20%). Resistance to amoxicillin-clavulanic acid was up to 47% (95% CI 43-50%), to ciprofloxacin 34% (95% CI 31-37%) and to cotrimoxazole 37% (95% CI 34-39) in urine cultures from outpatients. In contrast, low levels of carbapenem resistant Enterobacterales and Pseudomonas aeruginosa were observed.

Conclusions: Antimicrobial resistance is high and widespread across several important antibiotic classes. The widespread occurrence of MRSA and resistance to third-generation cephalosporins highlights the importance of identifying risk factors, enabling more effective guidance for antimicrobial stewardship.