Antimicrobial Resistance and Infection Control最新文献

Background: To quantify the incidence of peripheral intravenous catheter (PIVC) infections and to describe the influence of clinical characteristics, including dwell time, on risk.

Methods: Meta-synthesis of 18 prospective studies (16 randomized controlled trials and two prospective cohort studies) reporting PIVC infections. In total, 14,606 PIVCs (50,096 device-days) were studied from insertion to removal in seven Australian government hospitals. PIVC care was provided by clinical staff with daily follow up by research nurses. We calculated incidences and rates of local infection (without bloodstream infection [BSI]) and PIVC-associated bloodstream infection (i.e., primary BSI) using the National Healthcare Safety Network criteria. The hazard function was assessed by fitting a parametric survival model. PIVC-associated BSI was further categorized as PIVC-related BSI and/or Staphylococcus aureus BSI. Case study methodology explored characteristics of PIVC-associated BSI, and life tables explored the hazard function of PIVC-associated BSI over dwell time.

Results: Of 14,606 PIVCs (dwell 0-42 days), there were five local infections (0.034%; 0.100/1,000 device-days) and six PIVC-associated BSI (0.041%; 0.120/1,000 device-days), of which four were PIVC-related and one was S. aureus BSI. PIVC-associated BSI involved Enterobacter cloacae (n = 3 including one co-infection with Citrobacter braakii), Proteus mirabilis (n = 1), Pseudomonas aeruginosa (n = 1) and S. aureus (n = 1; S. aureus BSI incidence 0.007% catheters or 0.020/1000 device-days). PIVC-associated BSI cases commonly featured: males > 60 years with difficult intravenous access, delayed removal of idle or symptomatic PIVCs, cancer diagnoses, invasive gastrointestinal drains/procedures, insertion site complications, and forearm placement. PIVC-associated BSI daily hazard was constant over time with zero to 0.03% on Days 1 to 5 (n = 11,491), 0.06% to 0.10% on Days 6 and 7 (n = 2,571), and zero on Days 8 to 42 (n = 544).

Conclusions: Infection incidence is very low but remains a serious risk, mainly for complex patients. Gram-negative organisms may now be predominant in Australia. Infection surveillance should be risk-adjusted and prevention efforts to improve both insertion and post-insertion management targeted at high-risk groups. While overall intravenous therapy (exposure) should be minimised, daily risk per PIVC appears constant for at least 5 days.

Background: Serratia marcescens complex (SMC) is a group of opportunistic pathogens frequent in neonatal intensive care unit (NICU) outbreaks. We report a seven-month NICU outbreak of multidrug-resistant (MDR) SMC strain and assess the acquisition risk factors.

Methods: Bacterial isolates were sequenced using Illumina technology and profiled for antimicrobial resistance (AMR). Cases (culture positive for SMC) were compared with birth date and ward-matched controls (SMC negative) to identify clinical and environmental factors associated with SMC acquisition.

Results: A single strain of Serratia bockelmannii caused 42 cases from June 2022 to January 2023. All sequenced isolates (n = 49) carrued the same AMR genes, while the antibiogram (n = 32) assigned 15 strains as MDR, and 17 as non-MDR. The outbreak strain was recovered from ward surfaces and an analytical study revealed that beds used by several cases increased the acquisition odds by 3.27 (95%CI 1.71-8.77, p-value = 0.003) after adjusting for sex and length of stay.

Conclusions: The genomic typing was pivotal in confirming clonality across S. bockelmannii isolates with varied antibiograms, and identifying the bacterial species. Serratia bockelmannii should be considered during SMC outbreaks. Incubator-related within-ward transmission highlights the need for tailored risk assessments and disinfection protocols to prevent pathogen transmission and to improve infection prevention protocols.

Background: Vancomycin-resistant Enterococci (VRE) strains are a growing public health concern globally; however, epidemiological data to inform infection prevention and control interventions in line with antimicrobial resistance (AMR) global and national action plans in our study setting are limited. Here, we assessed VRE asymptomatic faecal carriage, AMR profiles and risk factors among inpatients and outpatients in a county referral hospital in Kenya.

Methods: This was a cross-sectional study design among adult patients (≥ 18) at the Kiambu County Referral Hospital outpatient department (OPD) and patients in the inpatient department (IPD) from June to September 2022. A systematic random sampling technique was employed to recruit 155 participants from the OPD, excluding patients presenting with histories of diarrhoea, antibiotics use (≤ 48 h), and ≤ 90 days previous admission. In IPD, 155 patients admitted for ≥ 48 h, were consecutively enrolled, excluding diarrhoea cases. The participants' sociodemographic and clinical data were collected using a structured questionnaire, with stool samples collected in sterile containers and transported in an icebox to Kenya Medical Research Institute, Nairobi, for analysis within 4-6 h, using standard and automated bacteriological methods.

Results: The overall faecal carriage of VRE was 5.2%, 95% confidence interval (CI): 2.98-8.25% (16/310), highest among the outpatients (3.9%; 12/310), 95% CI: 2.02-6.66%) where Enterococcus faecium predominated (overall: 62.5%, 10/16; IPD: 18.8%, 3/16; OPD: 43.8%, 7/16). VRE isolates were 100% resistant to erythromycin and tetracycline, with 31.3% (5/16) non-susceptible to teicoplanin, but remained sensitive to linezolid, tigecycline, and nitrofurantoin. Sixty-three per cent (62.5%, 10/16) of VRE isolates were multidrug-resistant, predominated by E. faecium (80%, 8/10). The multiple antibiotic resistance index (MARI) was > 0.2. The independent predictors of VRE carriage were female gender (aOR = 10.8, 95% CI 1.1-110.1, p = 0.045) and antibiotic dose completion behaviour (aOR = 0.122, 95% CI 0.0002-1.0, p = 0.046) among the outpatients.

Conclusion: We report asymptomatic faecal carriage of VRE strains that are MDR predominately among outpatients, whereby females and patients with a history of not completing an antibiotic prescription were at increased risk of colonization. To inform infection prevention interventions, establishing the transmission mechanisms and sustained AMR surveillance are warranted to mitigate VRE spread in our study area.

Background: Patients in burn intensive care units (BICUs) are at high risk of infections caused by multidrug-resistant pathogens, which can lead to hospital outbreaks.

Aim: To investigate an outbreak caused by carbapenem-resistant Acinetobacter baumannii (CRAB) in a BICU at a tertiary care hospital in Madrid, Spain, using whole-genome sequencing (WGS) and antibiotic susceptibility testing.

Methods: CRAB isolates were obtained from rectal swabs collected during routine epidemiological screening of BICU patients, as well as clinical and environmental samples collected throughout the outbreak. The genomes of the isolates were sequenced using Ion Torrent™ and MinION™ technologies. Antibiotic susceptibility testing was conducted by microdilution using the MicroScan NF50 panel. Susceptibility to cefiderocol was tested using disk diffusion and broth microdilution (ComASP^®).

Findings: The outbreak occurred between October 2022 and August 2023, affecting 26 patients (median age: 56 years, IQR 34-70). Genomic analysis identified the isolates as belonging to ST2/ST451 (Pasteur/Oxford schemes), carrying bla_OXA-23 carbapenemase gene. Environmental sampling detected CRAB on 20 of 105 tested surfaces. The outbreak's genomic evolution included the emergence of hypermucoid isolates and bla_ADC-73 mutants with increased cefiderocol minimum inhibitory concentrations (MICs). Novel mutations and combinations in bla_ADC-73 were observed, likely selected under cefiderocol pressure. Antibiotic susceptibility testing using the microdilution method was more sensitive in detecting these mutations. The outbreak ultimately necessitated the closure of the BICU for disinfection with high-concentration H₂O₂.

Conclusions: WGS enabled detailed tracking of CRAB's genomic evolution during the outbreak, identifying mutations associated with increased cefiderocol MICs. This information supported effective infection control measures, highlighting the utility of WGS in managing hospital outbreaks.

Background: In low and middle-income countries (LMICs), infections acquired during childbirth contribute significantly to maternal and neonatal mortality. Hand hygiene (HH) is critical in preventing the spread of infections, yet compliance remains inadequate. This study investigates birth attendants' HH compliance during labour, delivery, and postpartum in LMICs, using nationally representative data from Service Provision Assessments (SPAs) in Kenya, Malawi, and Nepal.

Methods: We analysed 1565 observed deliveries across 517 health facilities, resulting in 3919 HH opportunities. The outcomes were hand washing or hand disinfectant use: (1) before any initial examination, (2) before aseptic procedures during labour, (3) after birth. We used descriptive statistics to assess HH compliance and multivariate multilevel mixed-effect logistic regressions to investigate determinants, accounting for facility and individual clustering.

Findings: Hand hygiene compliance varied significantly across countries, with Kenya showing the lowest rates, while Malawi and Nepal had higher compliance levels. Supportive and effective communication towards pregnant women was significantly associated with an increase in HH compliance before the vaginal examination (Kenya - OR: 5.94, 95% CI 1.68-21.0; Malawi - OR: 2.19, 95% CI 1.04-4.65) and before aseptic procedures (Kenya - OR: 4.03, 95% CI 1.81-8.96; Malawi - OR: 4.01, 95% CI 1.69-9.50; Nepal - OR: 2.66, 95% CI 1.30-5.44). HH compliance during aseptic procedures during labour was also associated with recent IPC training in Malawi (OR: 3.48,95%CI 1.44-8.41) and facility infrastructure (OR: 6.14,95%CI 1.07-35.3).

Conclusion: Low hand hygiene compliance during birth, especially before aseptic procedures, can lead to healthcare-associated infections with serious consequences for mothers and newborns. Future research should investigate further the association between effective communication and hand hygiene.

Objectives: Carbapenem-resistant non-fermenting Gram-negative bacilli (CR Nf-GNB) infections present a significant challenge in intensive care units (ICUs). Despite being recognized as a significant clinical problem, comprehensive studies on the impact of CR Nf-GNB infections on patient morbidity and mortality remained limited.

Methods: Using data from the REA-REZO surveillance network, which includes 206 adult ICUs in France, we analysed patients admitted between 2016 and 2022 who developed healthcare-associated infections caused either by CR Nf-GNB or carbapenem-susceptible (CS) Nf-GNB. Propensity scores were calculated using a logistic regression model including relevant covariates, and CR and CS Nf-GNB patients were matched 1:1. The primary outcome was 30-day ICU survival, and secondary outcomes included 30-day reinfection (different pathogen) and relapse (same pathogen) rates.

Results: Among the 17,527 Nf-GNB infections, 3,171 were caused by CR strains. After matching, 1,498 patients were included in each group. CR Nf-GNB infections were independently associated with a significantly higher risk of death (adjusted sub-Hazard Ratio [sHR] 1.57 [95% CI, 1.40-1.76]) and increased reinfection rates (sHR 1.23 [95% CI, 1.01-1.50]) compared to CS Nf-GNB infections. CR infections also showed a higher proportion of reinfections with multidrug-resistant organisms.

Conclusion: CR Nf-GNB infections in ICU patients significantly increased mortality, and the risk of reinfection. CR Nf-GNB was not associated with a higher risk of relapse. These findings underscore the importance of targeted infection control measures and novel treatment strategies to manage CR Nf-GNB in critical care settings.

Background: The Xpert Carba-R assay allows direct identification of major carbapenemase genes from stools, offering faster results than culture-based methods. This study aimed to evaluate the diagnostic performance of the Xpert Carba-R assay for detecting CPE colonization and assess gene-level concordance between direct stool and cultured samples.

Methods: Between March and December 2023, two rectal swabs were collected from high-risk patients, those admitted to the intensive care unit or with prior hospitalization-at a tertiary care hospital. One swab was analyzed using the direct stool Xpert Carba-R assay, and the other underwent conventional culture techniques. Diagnostic performance was evaluated against culture-based detection, and concordance of carbapenemase gene identification between direct stool and culture isolate results was assessed.

Results: Among 4,120 screened patients, 107 (2.5%) were colonized with CPE. The direct stool Xpert assay showed a sensitivity of 97.2% and specificity of 99.1% for CPE detection. Concordance analysis showed an overall agreement of 64.1% (Cohen's kappa coefficient = 0.456). Discordance occurred in 52 cases (35.9%), primarily due to multiple gene detections in direct stool samples that were not confirmed in cultural isolates. The positive predictive value varied significantly by gene: bla_KPC showed 90.8%, bla_NDM 52.6%, bla_OXA-48 50.0%, while bla_IMP-1 showed 0%, with none of the nine bla_IMP-1 detections from stool samples confirmed in corresponding cultured isolates.

Conclusion: The Xpert Carba-R assay is a reliable tool for direct CPE detection from stool samples, though discordance with culture-based testing, particularly for bla_IMP-1-should be considered in clinical interpretation.

Background: Several countries have reported an increase in vancomycin-resistant Enterococcus faecium (VREF), a pathogen classified by the WHO as a high-priority threat due to its role in healthcare-associated infections and in-hospital mortality. This study aimed to describe temporal trends in VREF bloodstream infections in Italy from 2015 to 2023 and to explore patient and hospital characteristics associated with VREF.

Methods: We conducted a retrospective observational study using data from the Italian national antimicrobial resistance surveillance system (AR-ISS). All E. faecium bloodstream isolates tested for vancomycin resistance between 2015 and 2023 were included in the trend analysis. To examine associations with individual (sampling year, season, sex, age group, hospital unit, and geographical area) and hospital-level (number of beds, average length of stay, turnover index, bed occupancy rate, and turnover interval) characteristics, we focused on hospitalized adults (≥ 18 years) from 2022 to 2023. Mixed-effects logistic regression models were used to estimate trends and assess associations, with hospitals included as a random effect.

Results: Among 29,050 E. faecium isolates, the proportion of VREF rose from 11.5% in 2015 to 32.4% in 2023. Central Italy recorded the highest resistance in 2023 (44.8%), while the South and Islands showed the steepest relative increase (from 1.8% to 29.4%). In the 2022-2023 dataset, multivariable analysis showed higher odds of VREF among patients aged 40-79 years (versus ≥ 80 years; OR = 1.18, 95% CI: 1.02-1.38), those admitted to medical units (versus surgical units; OR = 1.18, 95% CI: 1.03-1.36), and in hospitals with more than 400 beds (versus < 400 beds; OR = 1.31, 95% CI: 1.09-1.58) or an average length of stay exceeding 10 days (versus ≤ 10 days; OR = 1.34, 95% CI: 1.07-1.69).

Conclusions: This study reveals a persistent increase in VREF bloodstream infections in Italy from 2015 to 2023. The findings highlight significant regional disparities and hospital characteristics linked to higher resistance rates, emphasizing the need for coordinated national and regional strategies. Strengthening integrated surveillance, antimicrobial stewardship, and infection prevention is essential to mitigate this growing public health concern.

Trial registration: Clinical trial number: not applicable.

Objective: To review the literature on caregiver involvement in infection prevention and control in low- and middle-income country (LMIC) neonatal units (NNUs).

Introduction: There is a high burden and mortality of neonatal infections globally, with most of the burden falling on LMIC. Healthcare-associated infections (HCAIs) are a particular challenge, with neonatal sepsis being one of the most common HCAIs. It is urgent to prevent infections, as both identification and treatment of neonatal sepsis are increasingly difficult in these contexts. Parents are consistently present on NNUs but their involvement in infection prevention and control (IPC) has been underexplored.

Inclusion criteria: Included studies were carried out in LMIC NNUs and reported on caregivers' involvement in design, implementation or experience of IPC interventions.

Methods: Five databases were searched in four languages and were screened by two authors. Reference searching was carried out of included papers. Data were analysed by each sub-question; caregiver involvement in intervention design (descriptive analysis), caregiver involvement in IPC delivery (quantitative analysis) and caregiver experience of hygiene and care (thematic analysis).

Results: 38 studies were included. Caregiver involvement in IPC design was limited, with examples from four papers. 30 papers contained information about caregiver delivery of IPC interventions. Most activities were related to being educated on IPC, carrying out core IPC activities or providing a specific aspect of an intervention (most frequently Kangaroo Mother Care). 10 papers discussed caregiver experience of NNU hygiene including ethnographic accounts from Ghana, Malawi, Mexico, India and Brazil. Across all contexts hierarchical social structures and challenging communication between healthcare professionals and families was a barrier to effective IPC within NNUs. Families showed a good understanding of core IPC practices and an awareness of contextual challenges of IPC.

Conclusion: Caregiver involvement in IPC is limited to date. However, interventions such as Kangaroo Mother Care indicate the benefits that can be achieved. Hierarchical structures and communication challenges between healthcare professionals and families are a barrier to inclusion at present and must be addressed in any designed intervention.