Antimicrobial Resistance and Infection Control最新文献

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.

Background: Following identification of widespread Mycobacterium chimaera infections in 2013 associated with aerosolization from Sorin heater-cooler-devices (HCD), microbiological monitoring of HCDs has become mandatory in Switzerland.

Methods: Since 01/2016, four Maquet HCU40 (Getinge) HCDs have been in operation at the University Hospital Basel. Monthly water cultures for Gram-negative bacteria and mycobacteria were performed, including samples from two filling lines equipped with 0.2 μm water filters. Intermittent monthly air sampling for mycobacteria was conducted.

Results: Between 01/2016 and 05/2018, various non-fermenting bacteria were cultured. Mycobacterium chelonae was first isolated in 06/2018 from HCD water tanks. Mycobacteria cultures from the filling lines remained negative. The first air sample positive for M. chelonae was collected in 12/2019. Despite intensified disinfection measures from 01/2022 onwards, M. chelonae could be cultured in air samples, collected at 30 cm and 120 cm height adjacent to three of the four running HCDs in 07/2022. Whole genome sequencing identified a cluster of isolates differing by a maximum of four single nucleotide polymorphisms. Despite extensive investigations, the source of M. chelonae remains undetermined. To date, no infections with M. chelonae have been related to the contaminated HCDs at our institution.

Conclusions: Our data confirms the risk of aerosolization of non-tuberculous mycobacteria from HCDs, irrespective of HCD-design and manufacturer. These findings underscore the importance of routine microbiological surveillance, including both water and air sampling when HCDs are placed within the operation room to prevent exposure of the operating field to the air exhausts of HCDs.

Aim: Central venous catheters (CVCs) are essential for long-term therapies but carry a high risk of central line-associated bloodstream infections (CLABSIs), which significantly impact patient outcomes and healthcare costs. This study aimed to develop a causal model for CLABSI using expert knowledge to guide future clinical trials and prevention strategies.

Methods: We constructed a directed acyclic graph (DAG) informed by literature and expert knowledge elicitation. A multidisciplinary team of clinicians, including infectious disease and vascular access experts, participated in interviews and workshops to refine the DAG, resulting in a final model with 30 variables representing CLABSI development.

Findings: The expert-elicited DAG identified two main pathways, patient-related and CVC-related, each contributing to CLABSI risk. Variables and relationships in the DAG highlighted key patient characteristics, CVC management practices, and overlapping factors influencing infection. This model serves as a novel framework to understand CLABSI causation and supports trial design by identifying confounding factors, causal pathways, and meaningful endpoints.

Conclusions/implications: Our causal DAG provides a structured representation of CLABSI risk factors, which may support the design of clinical trials examining interventions to reduce CVC-related infections. By clarifying causal mechanisms, the DAG can enhance the specificity of endpoints and improve the rigor of prevention strategies.

Background: In recent years, the detection of Klebsiella pneumoniae (KLPN) producing New Delhi metallo-β-lactamase (NDM), particularly NDM-1, has increased in Germany. Plasmids play a crucial role in the dissemination of NDM-1, facilitating its persistence in both clinical and environmental reservoirs. Between 2021 and 2024, a substantial number of NDM-1-producing KLPN isolates were detected across multiple hospital sites in Berlin. This study aimed to investigate a potential multi-site outbreak involving NDM-1-producing KLPN, and to assess the role of clonal versus plasmid-mediated dissemination.

Methods: We performed short-read sequencing for all isolates, complemented by long-read sequencing for a subset (Illumina and Oxford Nanopore Technologies). Core genome multi locus sequence typing (cgMLST) was conducted using SeqSphere+. NDM-1 plasmids were characterized with the MOB-suite tools. Reference plasmids were reconstructed from hybrid assemblies using TaDReP. Short-read sequences from all isolates were aligned against these reference plasmids to assess genetic relatedness.

Results: Analysis of 57 NDM-1 plasmid carrying KLPN isolates at the clonal level revealed three distinct outbreak clusters (O1-O3). These corresponded to three unique NDM-1 reference plasmids: p1 (54.0 kb IncFIB(pQil)), p2 (54.3 kb IncR), and p3 (355.5 kb; no Inc type specified). Plasmid clustering from short-reads was consistent with the clonal clusters.

Conclusions: Both plasmid-level analysis and cgMLST yielded congruent results, effectively ruling out the possibility of multi-site, plasmid-mediated NDM-1 transmission. The detection of a globally disseminated NDM-1 plasmid within one of the clonal clusters highlights its potential role in the spread of resistance during the recent surge of NDM-1 carrying KLPN isolates in Germany.