Antimicrobial Resistance and Infection Control最新文献

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.

Background: Antimicrobial stewardship programmes (ASP) are crucial for mitigating antimicrobial resistance (AMR), a growing threat in the Eastern Mediterranean region (EMR) where conflict, instability, and economic challenges hinder health systems. EMR specific barriers of antimicrobial stewardship (AMS) remain under documented.

Methods: A mixed methods study was conducted to explore barriers and opportunities for ASP implementation in EMR focusing on low (LIC) and lower middle-income countries (LMIC) with relatively stable policy environments and demonstrated interest, capacity, and infrastructure for stewardship. We used literature review, semi-structured interviews of experts, and a stakeholder consultation.

Results: Seven key themes emerged: One, AMS implementation capacity varies across the region, necessitating tailored approaches. Two, the limited availability of expertise requires urgent upscaling of knowledge and capacity. Three, mentorship and the development of centres of excellence is needed. Four, existing AMS tools should be enhanced, disseminated, and occasionally, adjusted to local needs. Five, the lack of a sustainable platform for networking impedes collaboration. Six, accreditation and national level mandates for hospital AMS can support scale-up. Seven, expanding research is critical to inform local evidence-based action.

Conclusions: Several components of ASPs are achievable in the EMR using existing resources with targeted support from local and identified regional and global partners.

Introduction: Monitoring surgical site infections (SSIs) incidence through surveillance systems enables tailored infection prevention interventions. In our facility, annual surveillance of SSIs in breast surgeries revealed a significant increase of SSI incidence rates six times higher than the national average in France in 2024. This study aimed to investigate the factors contributing to the increase in SSIs following breast surgery at the South Hospital Group of the Hospices Civils de Lyon (HCL), Pierre-Bénite, France.

Methods: The study was divided into three parts, all including breast surgeries: (1) an observational audit of professional practices assessing the compliance of operator attire in the operating room, conducted from May 30 to July 5, 2024), (2) an observational audit assessing the compliance of patient preoperative skin preparation, (May 30-July 5, 2024), (3) a retrospective case-control study nested within a prospective cohort of adult women who underwent breast surgery between January 1, 2019, and June 1, 2024.

Results: Overall, out of 220 observations, 207 (94%) professionals wore a mask upon entering the operating room, and 192 (87%) wore a mask that covered both the chin and nose. Of the 25 skin preparation observations, six (24%) antiseptic applications did not dry naturally, and 10 (40%) did not dry for at least 30 s. The case-control study revealed that coagulase-negative staphylococci and Staphylococcus aureus were the most prevalent pathogens. A BMI > 30 kg/m² was a risk factor for SSIs in breast surgery (OR = 3.21, 95% CI [1.57-6.56), as well as diabetes (OR = 3.09, 95% CI [1.16-8.31]) and the administration of antibiotic prophylaxis other than cefazolin (OR = 6.49, 95% CI [1.12-37.44]). Traceability of disinfection in the patient record with an alcohol-based antiseptic agent was a protective factor against the occurrence of SSIs (OR = 0.48, 95% CI [0.24-0.97]).

Conclusion: This multimodal study identified significant non-compliance regarding the wearing of caps, masks, and jewellery, as well as patient skin preparation. Obese and diabetic patients, as well as those receiving prophylactic antibiotics other than cefazolin, are particularly at risk for SSIs. Delving deeply into the reasons why professionals disregard recommendations related to operating room attire and antisepsis could be highly beneficial for the prevention of SSIs.

Background: Air changes per hour (ACH) in operating rooms (ORs) are energy intensive, and optimal air change settings are not known.

Objectives: We sought to explore whether there is a relationship between surgical site infections (SSIs) across states based on their state-mandated ACHs.

Design: Ecological, descriptive, cross-sectional study of publicly reported SSI data in the United States.

Methods: Wilcoxon test was used to investigate differences between SSI rates for specific surgery types between ACH mandate levels (15 and 20 ACH). Uni- and multivariable Poisson models at the state level were fitted to estimate differences in SSI rates for each surgery type.

Results: OR ACH mandates and SSIs were positively correlated for C-sections and spinal fusion; negatively correlated for colon and laminectomy surgery.

Conclusion: For most surgery types, there is no correlation between state-mandated OR ACH. Further studies are needed to determine what changes to mandates can be made safely and effectively.