Antimicrobial-resistant Organisms Research Articles

Antibiotic use and resistance: Assessment of healthcare workers’ knowledge, attitude, and practice

Background: Multidrug resistant bacteria have become a major public health concern worldwide. Inappropriate and overuse of antibiotics are known promoters of antibiotic resistance. This study was therefore carried out to assess healthcare workers’ knowledge, attitude, and practice on antibiotic use and resistance. Materials and Methods: A descriptive cross-sectional study was conducted among healthcare workers from University of Nigeria Teaching Hospital (UNTH) Enugu, Nigeria. A self-administered questionnaire was used to assess the knowledge, attitude, and practice of antibiotic use and resistance. Descriptive and inferential analyses were subjected on the data. Results: A total of 600 healthcare workers were surveyed with male: female ratio of 1:2.2. The mean age of the participants was 39.6±25.6 years. The level of knowledge was 58.8%, followed by attitude (49.1%) and practice (24.3%). The knowledge on super bugs (40.3%) and carbapenem-resistant Enterobacteriaceae (37.3%) was the least on resistant organisms surveyed. The main source of information was internet with the least being television/newspaper. Slightly less than half, (287/600, 47.8%) always do laboratory investigations before commencing antibiotics and (373/600, 62.2%) will stop taking antibiotics when their symptoms improve without completing the dosage. Majority of the participants (91.2%) indicated that healthcare workers are at risk of acquiring the antimicrobial-resistant organisms; however, only 67.7% believed that UNTH has the same problem. Conclusion: The knowledge, attitude, and practice of healthcare workers on antibiotic use and resistance were not encouraging. Greater educational interventions are, therefore, necessary to improve public awareness and develop behavioral measures to curb the spread of the resistant organisms.

Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy

IntroductionIntraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. MethodsWe performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. ResultsIn total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. ConclusionsIAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. Level of evidenceLevel III

818. Understanding Current Practices of an Electronic Antimicrobial Resistant Organism (ARO) Screening Tool Used in Healthcare Facilities in Alberta, Canada

Abstract Background Increasing antibiotic resistance is a global problem. By detecting individuals colonized with antimicrobial resistant organisms (AROs) through hospital admission screening, enhanced precautions can be implemented to interrupt transmission during their hospitalization. The objective is to understand current practices of ARO screening in Alberta hospitals by evaluating completeness of an electronic ARO screening tool. Methods A retrospective cohort study using electronic medical record (EMR) data from Connect Care (Epic Systems Corp.) at one adult and one pediatric tertiary hospital in Edmonton, Alberta between January 1, and December 31, 2020 was conducted. All hospital admissions were included. Outcomes included proportion of admissions with a completed ARO tool and a comparison of the best practice actions triggered (e.g. ARO screening swab and/or isolate) between those with and without a completed ARO tool. Test of proportions was used, with a two-sided α of 0.05 and was conducted using STATA/SE 16.1. Results During the study period, there were 32,600 total admissions, of which 16,342 (50.1%) had the ARO tool completed. The overall compliance was greater in the adult hospital (53.9%) compared to the pediatric hospital (36.3%) (< 0.001). For both hospitals, the compliance rate in December 2020 was 30.0% lower than in January 2020, with a continuous decline during the 12 months. An isolation order or screening swab was ordered in 40.6% of admissions without an ARO tool completed compared to 56.5% of admissions with the ARO tool completed. Based on responses in the completed ARO tool, 81.2% of patient admissions had a microbiologic swab ordered when indicated, of which only 4.7% were positive. However, only 35.9% of patient admissions had additional precautions ordered when indicated. Conclusion ARO screening is a required organizational practice and although standardized across all Alberta hospitals and embedded within an EMR, compliance was poor. Further work is needed to understand point-of-care risk assessment processes to inform future interventions aimed at early identification and decreased transmission of ARO in hospitals. Disclosures All Authors: No reported disclosures

1277. Colonization Rates for Antimicrobial-resistant Bacteria in Kenya: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BackgroundCharacterization of antimicrobial-resistant organism (ARO) colonization is critical to understand transmission dynamics and infection risk, however data in resource-limited settings are scare. We estimated the prevalence of Enterobacterales colonization with extended-spectrum cephalosporin-resistance (ESCrE), carbapenem-resistance (CRE) and methicillin-resistant Staphylococcus aureus (MRSA) among community residents and hospitalized patients in rural (Siaya County) and urban (Kibera) Kenya.MethodsCommunity-dwelling adults and children were enrolled via cluster randomized sampling. Inpatients of all ages were enrolled by simple random sampling. Stool/rectal and nasal swabs were collected and screened for ESCrE, CRE and MRSA, respectively, using HardyChrom™ media. Vitek2® was used for isolate confirmation and antibiotic susceptibility testing. Fisher’s exact tests were used to compare prevalence of AROs.ResultsThe prevalence of ESCrE was higher for the urban hospital (69.8%, 263/377) compared to rural hospitals (62.7%, 298/475, P=0.04); a similar pattern was evident for CRE (16.7%, 63/377 and 6.5%, 31/475, respectively, P< 0.01). The prevalence of MRSA was 3.2% for both urban and rural hospitals (P=0.99). For adults, the prevalence of ESCrE was higher in Kibera households (51.4%, 346/673) compared to Siaya (44.6%, 283/634, P=0.02) while the prevalence of both CRE and MRSA was < 3% for both areas and did not differ significantly (CRE, P=0.13, MRSA, P=0.14). There was no significant difference between urban and rural children for ESCrE (47.7%, 74/155 and 53.4%, 135/253, P=0.31); both CRE and MRSA were rarely detected (< 2%) with no difference across settings (CRE, P=1.0, MRSA, P=0.42). Among Enterobacteriaceae recovered, Escherichia coli and Klebsiella spp. predominated.ConclusionColonization with AROs were widespread in households and hospitals in urban and rural areas. Hospitals with elevated prevalence of highly transmissible AROs should consider whether implementation of colonization screening can be incorporated as part of their infection prevention and control programs. Risk factors for ARO colonization should be elucidated to identify novel prevention strategies.Disclosures All Authors: No reported disclosures

Diagnosis and Treatment of Bacterial Pneumonia in Critically Ill Patients with COVID-19 Using a Multiplex PCR Assay: A Large Italian Hospital's Five-Month Experience.

ABSTRACTBacterial pneumonia is a challenging coronavirus disease 2019 (COVID-19) complication for intensive care unit (ICU) clinicians. Upon its implementation, the FilmArray pneumonia plus (FA-PP) panel’s practicability for both the diagnosis and antimicrobial therapy management of bacterial pneumonia was assessed in ICU patients with COVID-19. Respiratory samples were collected from patients who were mechanically ventilated at the time bacterial etiology and antimicrobial resistance were determined using both standard-of-care (culture and antimicrobial susceptibility testing [AST]) and FA-PP panel testing methods. Changes to targeted and/or appropriate antimicrobial therapy were reviewed. We tested 212 samples from 150 patients suspected of bacterial pneumonia. Etiologically, 120 samples were positive by both methods, two samples were culture positive but FA-PP negative (i.e., negative for on-panel organisms), and 90 were negative by both methods. FA-PP detected no culture-growing organisms (mostly Staphylococcus aureus or Pseudomonas aeruginosa) in 19 of 120 samples or antimicrobial resistance genes in two culture-negative samples for S. aureus organisms. Fifty-nine (27.8%) of 212 samples were from empirically treated patients. Antibiotics were discontinued in 5 (33.3%) of 15 patients with FA-PP-negative samples and were escalated/deescalated in 39 (88.6%) of 44 patients with FA-PP-positive samples. Overall, antibiotics were initiated in 87 (72.5%) of 120 pneumonia episodes and were not administered in 80 (87.0%) of 92 nonpneumonia episodes. Antimicrobial-resistant organisms caused 78 (60.0%) of 120 episodes. Excluding 19 colistin-resistant Acinetobacter baumannii episodes, AST confirmed appropriate antibiotic receipt in 101 (84.2%) of 120 episodes for one or more FA-PP-detected organisms. Compared to standard-of-care testing, the FA-PP panel may be of great value in the management of COVID-19 patients at risk of developing bacterial pneumonia in the ICU.IMPORTANCE Since bacterial pneumonia is relatively frequent, suspicion of it in COVID-19 patients may prompt ICU clinicians to overuse (broad-spectrum) antibiotics, particularly when empirical antibiotics do not cover the suspected pathogen. We showed that a PCR-based, culture-independent laboratory assay allows not only accurate diagnosis but also streamlining of antimicrobial therapy for bacterial pneumonia episodes. We report on the actual implementation of rapid diagnostics and its real-life impact on patient treatment, which is a gain over previously published studies on the topic. A better understanding of the role of that or similar PCR assays in routine ICU practice may lead us to appreciate the effectiveness of their implementation during the COVID-19 pandemic.

Barriers and facilitators to infection prevention and control in Dutch residential care facilities for people with intellectual and developmental disabilities: A theory-informed qualitative study.

BackgroundCare institutions are recognised to be a high-risk setting for the emergence and spread of infections and antimicrobial-resistant organisms, which stresses the importance of infection prevention and control (IPC). Accurate implementation is crucial for optimal IPC practice. Despite the wide promotion of IPC and research thereof in the hospital and nursing home setting, similar efforts are lacking in disability care settings. Therefore, this study aimed to assess perceived barriers and facilitators to IPC among professionals working at residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDD), as well as to identify professional-reported recommendations to improve IPC.MethodsThis qualitative study involved semi-structured interviews (before COVID-19) with twelve professionals from five Dutch RCFs for people with IDD. An integrated theoretical approach was used to inform data collection and analysis. Thematic analysis using inductive and deductive approaches was conducted. This study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.ResultsOur findings revealed barriers and facilitators at the guideline, client, professional, professional interaction, professional client interaction, client interaction, organisational, community, and societal level. Six main themes covering multiple barriers and facilitators were identified: (1) guidelines’ applicability to (work)setting; (2) professionals’ cognitions and attitude towards IPC (related to educational background); (3) organisational support and priority; (4) educational system; (5) time availability and staff capacity; and (6) task division and change coaches. The main professional-reported recommendations were the introduction of tailored and practical IPC guidelines, structural IPC education and training among all professionals, and client participation.ConclusionsTo promote IPC, multifaceted and multilevel strategies should be implemented, with a preliminary need for improvements on the guideline, professional, and organisational level. Given the heterogeneous character, i.e., different professionals, clients and care needs, there is a need for a tailored approach to implement IPC and sustain it successfully in disability care. Our findings can inform future IPC practice improvements.

Critically important antimicrobial resistant Enterobacteriaceae in Irish farm effluent and their removal in integrated constructed wetlands

This study investigated the ability of Integrated Constructed Wetlands (ICWs) to remove critically important antimicrobial resistant organisms (AROs) from farm wastewater. Influent samples from the untreated farm waste and effluent samples taken at the end of the ICW system were collected monthly from four ICWs, serving four different farm types (suckler, dairy, dairy & poultry and pig). Using selective media to screen for the presence of carbapenemase resistant organisms, plasmid mediated and AmpC β-Lactamase producing organisms (ESBL/pAmpC) and fluoroquinolone resistant organisms, a total of 82 AROs were obtained with the majority being E. coli (n = 79). Statistically significant were the differences on the number of AROs isolated from influent (higher) compared to effluent, as well as a seasonal effect, with less AROs recovered during winter in comparison to other seasons (P < 0.05). On the other hand, there was no significant differences in the recovery of AROs on different farms. The majority of isolates from each of the farms (99%) were multi drug resistant, with 65% resistant to seven or more antimicrobials. A high incidence of tetracycline, trimethoprim/sulfamethoxazole, and ampicillin resistance was common to the isolates from all four farms but there were differences in ESBL levels with 63% of the isolates recovered from Farm 4 (piggery) being ESBLs compared to 18%, 36% and 4.5% recovered from Farms 1 (suckler), 2 (dairy) and 3 (dairy & poultry), respectively. No carbapenemase producing organisms were isolated. Our results showed that ICWs are effective in removing critically important AROs from farm wastewater on all four farm types.

A review of antimicrobial resistance in imported foods.

Antimicrobial resistance is one of the most serious threats to medical science. Food supply is recognized as a potential source of resistant bacteria, leading to the development of surveillance programs targeting primarily poultry, pork, and beef. These programs are limited in scope, not only in the commodities tested, but also in the organisms targeted (Escherichia coli, Salmonella, and Campylobacter); consequently, neither the breadth of food products available nor the organisms that may harbour clinically relevant and (or) mobile resistance genes are identified. Furthermore, there is an inadequate understanding of how international trade in food products contributes to the global dissemination of resistance. This is despite the recognized role of international travel in disseminating antimicrobial-resistant organisms, notably New Delhi metallo-beta-lactamase. An increasing number of studies describing antimicrobial-resistant organisms in a variety of imported foods are summarized in this review.

Evaluation of antimicrobial and synergistic effects of some medicinal plant extracts on antimicrobial resistant organisms

Background: To evaluate antimicrobial activity of ten plant extracts on antimicrobial resistant organisms and investigate interactions of these extracts with antimicrobials against resistant organisms. Methods: The antimicrobial potential of ethanolic leaf extract of Aberia caffra Hook. f. & Harv., Azadirachta indica L., Dodonaea viscosa L., Ficus nitida L., Lanatana camara L., Myrtus communis L., Olea europaea L., Ruta graveolens, Schinus terebinthifolius Raddi and Vitex agnus-castus L. was investigatedagainst eleven drug resistant organisms by agar well diffusion method. The interaction of these extracts with antimicrobials was assessed. Results: Ethanolic extracts of Dodonaea viscosa leaves had antibacterial activity against ESBL-producing Escherichia coli (E. coli) quinolone resistant Salmonella typhi (S. typhi) andESBL and carbapenemase-producing Klebsiella pneumonia (K. pneumonia).Schinus terebinthifolius Raddi leaves showed antibacterial activity against ESBL and carbapenemase-producing K. pneumoniae and fluconazole resistant C. albicans. Myrtus communis leave extracts demonstrated activity against ESBL-producing E. coli and fluconazole resistant A. fumigatus. Ruta graveolens L. revealed activity against quinolone resistant S. typhiand fluconazole resistant A. fumigatus. Vitex agnus-castus, Aberia caffra Hook. f. &Harv.andAzadirachta indica L. leaf extracts had activity against ESBL-producing E. coli. Olea europaea L. had activity against quinolone resistant A. baumannii. Ruta graveolens L. and Myrtus communis L. were the only extracts showing synergistic effect in association with voriconazole against fluconazole resistant A. fumigatus. Conclusion: Tested plant leaf extracts had great potential as antimicrobial agents against at least one drug resistant microorganism. Isolation of active components and further studies are needed to evaluate the efficacy and toxicity of these products.

Identifying asymptomatic spreaders of antimicrobial-resistant pathogens in hospital settings

Antimicrobial-resistant organisms (AMROs) can colonize people without symptoms for long periods of time, during which these agents can spread unnoticed to other patients in healthcare systems. The accurate identification of asymptomatic spreaders of AMRO in hospital settings is essential for supporting the design of interventions against healthcare-associated infections (HAIs). However, this task remains challenging because of limited observations of colonization and the complicated transmission dynamics occurring within hospitals and the broader community. Here, we study the transmission of methicillin-resistant Staphylococcus aureus (MRSA), a prevalent AMRO, in 66 Swedish hospitals and healthcare facilities with inpatients using a data-driven, agent-based model informed by deidentified real-world hospitalization records. Combining the transmission model, patient-to-patient contact networks, and sparse observations of colonization, we develop and validate an individual-level inference approach that estimates the colonization probability of individual hospitalized patients. For both model-simulated and historical outbreaks, the proposed method supports the more accurate identification of asymptomatic MRSA carriers than other traditional approaches. In addition, in silica control experiments indicate that interventions targeted to inpatients with a high-colonization probability outperform heuristic strategies informed by hospitalization history and contact tracing.

Molecular Epidemiology of Escherichia coli Clinical Isolates from Central Panama.

Escherichia coli represents one of the most common causes of community-onset and nosocomial infections. Strains carrying extended spectrum β-lactamases (ESBL) are a serious public health problem. In Central America we have not found studies reporting the molecular epidemiology of E. coli strains implicated in local infections, so we conducted this study to fill that gap. Materials and Methods: We report on an epidemiological study in two reference hospitals from central Panama, identifying the susceptibility profile, associated risk factors, and molecular typing of E. coli strains isolated between November 2018 and November 2019 using Pasteur’s Multilocus Sequence Typing (MLST) scheme. Results: A total of 30 E. coli isolates with antimicrobial resistance were analyzed, 70% of which came from inpatients and 30% from outpatients (p < 0.001). Two-thirds of the samples came from urine cultures. Forty-three percent of the strains were ESBL producers and 77% were resistant to ciprofloxacin. We identified 10 different sequence types (STs) with 30% of the ESBL strains identified as ST43, which corresponds to ST131 of the Achtman MLST scheme—the E. coli pandemic clone. Thirty-eight percent of the E. coli strains with the ESBL phenotype carried CTX-M-15. Conclusions: To the best of our knowledge, this is the first report confirming the presence of the pandemic E. coli clone ST43/ST131 harboring CTX-M-15 in Central American inpatients and outpatients. This E. coli strain is an important antimicrobial-resistant organism of public health concern, with potential challenges to treat infections in Panama and, perhaps, the rest of Central America.

Blood Cultures and Appropriate Antimicrobial Administration after Achieving Sustained Return of Spontaneous Circulation in Adults with Nontraumatic Out-of-Hospital Cardiac Arrest.

We aimed to determine the incidence of bacteremia and prognostic effects of prompt administration of appropriate antimicrobial therapy (AAT) on nontraumatic out-of-hospital cardiac arrest (OHCA) patients achieving a sustained return of spontaneous circulation (sROSC), compared with non-OHCA patients. In the multicenter case-control study, nontraumatic OHCA adults with bacteremia episodes after achieving sROSC were defined as case patients, and non-OHCA patients with community-onset bacteremia in the emergency department were regarded as control patients. Initially, case patients had a higher bacteremia incidence than non-OHCA visits (231/2171, 10.6% vs. 10,430/314,620, 3.3%; p < 0.001). Compared with the matched control (2288) patients, case (231) patients experienced more bacteremic episodes due to low respiratory tract infections, fewer urosepsis events, fewer Escherichia coli bacteremia, and more streptococcal and anaerobes bacteremia. Antimicrobial-resistant organisms, such as methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase-producing Enterobacteriaceae, were frequently evident in case patients. Notably, each hour delay in AAT administration was associated with an average increase of 10.6% in crude 30-day mortality rates in case patients, 0.7% in critically ill control patients, and 0.3% in less critically ill control patients. Conclusively, the incidence and characteristics of bacteremia differed between the nontraumatic OHCA and non-OHCA patients. The incorporation of blood culture samplings and rapid AAT administration as first-aids is essential for nontraumatic OHCA patients after achieving sROSC.

Antibiotic Resistance Pattern of Uropathogens in a Tertiary Care Hospital in Calabar, Nigeria

Introduction: Urinary tract infection is a major reason for hospital visits and a common clinical condition encountered by clinicians. The causative agents of urinary tract infection and their resistant pattern vary globally. The aim of this study was to highlight the profile of pathogens associated with urinary tract infections in our locality. The objective was to investigate the resistant pattern of these microbial isolates from patients with urinary tract infection and offer recommendations for effective treatment.&#x0D; Materials and methods: We retrospectively analyzed the urine culture and antimicrobial sensitivity reports of patients with suspected urinary tract infection at the University of Calabar Teaching Hospital, Calabar, Nigeria, from September 2019 to August 2020. Methicillin resistance was detected by disk diffusion method using 30 µg cefoxitin disk. Production of Extended spectrum beta lactamases was detected by the Combination disk and the double-disk synergy method.&#x0D; Results: Of 979 urine culture and sensitivity reports, 306 (31.26%) were positive for microbial growth. Two microbial isolates each were recovered from urine samples of 5 patients giving a total number of 311 isolates from 306 patients. 45.75% of positive results were in males. The predominant isolate was Escherichia coli (n=97, 31.19%). Extended Spectrum Beta Lactamases (ESBL) producing strains comprised 10.08% (10/238) of Gram-negative group of organisms, while 47.39% (145/306) of all bacterial isolates in our study were multi drug resistant (MDR). 14.29% (6/42) of S. aureus isolates were methicillin resistant S. aureus, while 33.33% (2/6) of methicillin resistant S. aureus (MRSA) were multi drug resistant.&#x0D; Conclusion: Urinary tract infection caused by antimicrobial resistant organisms is common among studied patients. This emphasizes the need for urine culture and sensitivity tests in the management of urinary tract infection.

Antimicrobial Resistance: A Situational Analysis in the Deido Health District, Douala, Cameroon

Background The rapid and ongoing spread of antimicrobial-resistant organisms threatens the ability to successfully prevent, control, or treat a growing number of infectious diseases in developed and developing countries. This study was designed to convey more insight on the profile of antimicrobial resistance and the capacity of laboratories conducting antimicrobial susceptibility testing in Cameroon. Methods A multicentre cross-sectional study was conducted from October 2019 to March 2020 in the Deido Health District. Laboratories that carry out culture and sensitivity testing within the Deido Health District were identified and assessed to determine their capacity as well as the quality of results from microbiological investigations. Information on antimicrobial susceptibility of various isolates was collected using tablet phones in which the study questionnaires had been incorporated. Results Gaps identified in antimicrobial susceptibility testing that cut across laboratories included; insufficient standard operating procedures, inadequate records on personnel training and competency assessment, lack of safety equipment such as biosafety cabinet, stock out and non-participation in external quality assurance program. The turnaround time for antimicrobial susceptibility testing ranged from 3 – 7 days. Out of the 1797 samples cultured, 437(24.3%) had at least one isolate. A total of 15 different isolates were identified with Candida albicans being the most frequent 178 (40.7%), followed by Escherichia coli 80(18.3%). Among the 15 classes of antimicrobial drugs used in this study, the overall resistance of the isolates showed that five classes had class median resistance above 40% (Cephalosporins, Penicillins, Beta-lactam, Macrolides, and Polyenes). Conclusion This study has shown the need to develop a coordinated national approach to fight antimicrobial resistance. Scaling-up of antimicrobial susceptibility testing will, therefore, require strengthening the microbiology units of laboratory systems as well as ensuring the use of laboratory data for decision making

Dosing Considerations for Combination Antistaphylococcal β-Lactam and Glyco/lipopeptide Salvage Therapy for Resistant Gram-Positive Infections: A Systematic Review.

The objective of this systematic review is to evaluate dosing regimens of combination salvage regimens used as part of infectious disease pharmacotherapy. A systematic review was conducted on PubMed, MEDLINE, Scopus, ProQuest Central, and CINAHL through March 2021 using the following terminology: "combination" OR "Seesaw" OR "see-saw" OR "salvage" AND "infection" OR "resistant infection" OR "Gram-positive" AND "beta-lactam" OR "cephalosporin" OR "carbapenem" OR "monobactam" OR "glycopeptide" OR "lipopeptide." Following the application of inclusion and exclusion criteria, 8 pieces of literature were ultimately included in this review. Vancomycin in combination with another agent was most commonly prescribed as initial or empirical therapy. The most common combination salvage therapy regimen consisted of daptomycin in doses up to 12 mg/kg IV every 24 hours with ceftaroline 200 to 600 mg IV every 8 to 12 hours. Although the duration of combination salvage therapy varied drastically, blood culture clearance was typically observed within 24 hours. Antimicrobial-resistant Gram-positive organisms have posed an emergent threat to antimicrobial stewardship initiatives. Utilizing either a glycopeptide or lipopeptide antibiotic in combination with an antistaphylococcal β-lactam antibiotic has demonstrated efficacy in treating resistant bacteria. This work describes the heterogeneity of dosing regimens and seeks to define an optimal dose, duration, and combination of antibiotics. Combination salvage therapy has demonstrated efficacy and safety in treatment of resistant Gram-positive infections. It appears the combination of daptomycin and ceftaroline can clear resistant infections expeditiously.

Development of a provincial interactive antibiogram tool forOntario.

Antimicrobial resistance (AMR) is a public health issue with significant impact on health care. Antibiogram development and deployment is a key strategy for managing and preventing AMR. Our objective was to develop an Ontario antibiogram as part of a larger provincial initiative aimed at advancing antimicrobial stewardship in the province. As part of a voluntary provincial online survey, antibiogram data from 100 of 201 (49.8%) Ontario hospitals were collected and included. All hospitals in Ontario were eligible to participate except those providing only mental health or ambulatory services. Weighted provincial and regional antibiotic susceptibilities (percentages) were conducted using descriptive statistical analyses, and an interactive antibiogram spreadsheet was developed. Respondent-identified barriers to collecting and interpreting antibiogram data are presented descriptively. There was wide regional variability in antimicrobial-resistant organisms across Ontario. Provincial methicillin-resistant Staphylococcus aureus prevalence was 24.6%, ranging from 5.9% to 43.7% regionally. Provincial Escherichia coli resistance to ceftriaxone and ciprofloxacin was 13.8% (regional range 6.0%-25.1%) and 22.5% (regional range 9.8-37.8%), respectively. Klebsiella spp resistance to ceftriaxone and ciprofloxacin was similar across all health regions, with overall provincial rates of 7.5% and 5.6%, respectively. We have demonstrated that integrating hospital AMR tracking and reporting as part of a larger voluntary provincial antimicrobial stewardship program initiative is a feasible approach to capturing AMR data. The provincial antibiogram serves as a benchmark for the current state of AMR provincially and across health regions.

Risk Factors for Mortality in Adult COVID-19 Patients Who Develop Bloodstream Infections Mostly Caused by Antimicrobial-Resistant Organisms: Analysis at a Large Teaching Hospital in Italy

The aim of this study was to characterize COVID-19 (SARS-CoV-2-infected) patients who develop bloodstream infection (BSI) and to assess risk factors associated with in-hospital mortality. We conducted a retrospective observational study of adult patients admitted for ≥48 h to a large Central Italy hospital for COVID-19 (1 March to 31 May 2020) who had or had not survived at discharge. We included only patients having blood cultures drawn or other inclusion criteria satisfied. Kaplan–Meier survival or Cox regression analyses were performed of 293 COVID-19 patients studied, 46 patients (15.7%) had a hospital-acquired clinically relevant BSI secondary to SARS-CoV-2 infection, accounting for 58 episodes (49 monomicrobial and 9 polymicrobial) in total. Twelve episodes (20.7%) occurred at day 3 of hospital admission. Sixty-nine species were isolated, including Staphylococcus aureus (32.8%), Enterobacterales (20.7%), Enterococcus faecalis (17.2%), Candida (13.8%) and Pseudomonas aeruginosa (10.3%). Of 69 isolates, 27 (39.1%) were multidrug-resistant organisms. Twelve (54.5%) of 22 patients for whom empirical antimicrobial therapy was inappropriate were infected by a multidrug-resistant organism. Of 46 patients, 26 (56.5%) survived and 20 (43.5%) died. Exploring variables for association with in-hospital mortality identified > 75-year age (HR 2.97, 95% CI 1.15–7.68, p = 0.02), septic shock (HR 6.55, 95% CI 2.36–18.23, p < 0.001) and BSI onset ≤ 3 days (HR 4.68, 95% CI 1.40–15.63, p = 0.01) as risk factors independently associated with death. In our hospital, mortality among COVID-19 patients with BSI was high. While continued vigilance against these infections is essential, identification of risk factors for mortality may help to reduce fatal outcomes in patients with COVID-19.

A randomized controlled trial of Lactobacillus rhamnosus GG on antimicrobial-resistant organism colonization.

Alteration of the colonic microbiota following antimicrobial exposure allows colonization by antimicrobial-resistant organisms (AROs). Ingestion of a probiotic, such as Lactobacillus rhamnosus GG (LGG), could prevent colonization or infection with AROs by promoting healthy colonic microbiota. The purpose of this trial was to determine the effect of LGG administration on ARO colonization in hospitalized patients receiving antibiotics. Prospective, double-blinded, randomized controlled trial of LGG versus placebo among patients receiving broad-spectrum antibiotics. Tertiary care center. In total, 88 inpatients receiving broad-spectrum antibiotics were enrolled. Patients were randomized to receive 1 capsule containing 1×1010 cells of LGG twice daily (n = 44) or placebo (n = 44), stratified by ward type. Stool or rectal-swab specimens were collected for culture at enrollment, during admission, and at discharge. Using selective media, specimens were cultured for Clostridioides difficile, vancomycin-resistant Enterococcus spp (VRE), and antibiotic-resistant gram-negative bacteria. The primary outcome was any ARO acquisition. Secondary outcomes included loss of any ARO if colonized at enrollment, and acquisition or loss of individual ARO. ARO colonization prevalence at study enrollment was similar (LGG 39% vs placebo 39%). We detected no difference in any ARO acquisition (LGG 30% vs placebo 33%; OR,1.19; 95% CI, 0.38-3.75) nor for any individual ARO acquisition. There was no difference in the loss of any ARO (LGG 18% vs placebo 24%; OR, 1.44; 95% CI, 0.27-7.68) nor for any individual ARO. LGG administration neither prevented acquisition of ARO nor accelerated loss of ARO colonization.

#74: Development of a Solid-Organ Transplant-Specific Antibiogram in a Tertiary Pediatric Hospital in Canada

Abstract Background Solid-organ transplant (SOT) patients are more vulnerable to infections by antimicrobial-resistant organisms (AROs) because of their hospital exposure, compromised immune systems, and antimicrobial exposure. Therefore, it may be useful for transplant facilities to create transplant-specific antibiograms to direct empirical antimicrobial regimens and monitor trends in antimicrobial resistance. Methods SOT (i.e., lung, liver, renal, and heart) antibiograms were created using antimicrobial susceptibility data on isolates from 2012 to 2018 at The Hospital for Sick Children, a tertiary pediatric hospital and transplant center in Toronto, Ontario. The Clinical Laboratory Standards Institute (CLSI) guidelines were followed to generate the antibiograms. The first clinical isolate of a species from a patient in each year was included irrespective of body site; duplicates were eliminated and surveillance cultures were excluded. Results from 2 years of data were pooled on a rolling basis to achieve an adequate sample size in both SOT and hospital-wide antibiogram. The SOT antibiogram was then compared with the hospital-wide antibiogram of the compatible 2 pooled years from 2012 to 2018. For subgroup analyses in the SOT population, organ-specific antibiograms and transplant timing-specific antibiograms (pretransplant, post-transplant &amp;lt;1 year, and post-transplant ≥1 year) between transplant and sample collection dates were analyzed. All proportions were compared using the χ 2 test. Results The top 5 organisms in one (2 year) analysis period of the SOT antibiogram were Escherichia coli (n = 29), Staphylococcus aureus (n = 28), Pseudomonas aeruginosa (n = 20), Enterobacter cloacae complex (n = 18), and Klebsiella pneumoniae (n = 17). For E.coli, susceptibility in the SOT antibiogram was significantly lower than those in the hospital-wide antibiogram in 2017/2018 for ampicillin (27% vs. 48%; P = 0.015), piperacillin/tazobactam (55% vs. 87%; P &amp;lt; 0.001), cefotaxime (59% vs. 88%; P &amp;lt; 0.001), ciprofloxacin (71% vs. 87%; P = 0.007) and cotrimoxazole (41% vs. 69%; P &amp;lt; 0.001), but not significantly different for gentamicin (94% vs. 91%; P = 0.490), tobramycin (88% vs. 90%; P = 0.701) and amikacin (100% vs. 99%; P = 0.558). These findings were consistent throughout the study period in E.coli. There was no statistically significant difference between the SOT and hospital-wide antibiograms for other organisms. There were no significant differences in susceptibility between organ-specific antibiograms or transplant timing-specific antibiograms in 2012–2018. Conclusions We found that E.coli from the SOT population had a significantly lower sensitivity to all antimicrobials, except aminoglycosides, compared with those from the hospital-wide population. Other organisms had similar susceptibility to the hospital-wide population. Developing a SOT antibiogram will assist in revising and improving empiric treatment guidelines for this population.

Solid organ transplant-specific antibiogram in a tertiary pediatric hospital in Canada.

SOT recipients are more vulnerable to infections with antimicrobial-resistant organisms, and therefore, it may be useful for transplant centers to create transplant-specific antibiograms to direct empirical antimicrobial regimens and monitor trends in antimicrobial resistance. SOT-specific antibiograms were created using antimicrobial susceptibility data on isolates from 2012 to 2018 at The Hospital for Sick Children, Toronto, Ontario, Canada. The CLSI guidelines were followed to generate the antibiograms except that results from 2years of data were pooled on a rolling basis to achieve larger sample sizes. The 3 most frequent organisms in one analysis period of the SOT antibiogram wereEscherichia coli (average sample size ±standard deviation; n=28.7±3.8), Staphylococcus aureus (n=27.8±5.0), and Pseudomonas aeruginosa (non-CF) (n=19.8±8.8). For E.coli, susceptibilities in the SOT antibiogram were significantly lower than those in the hospital-wide antibiogram in 2017-2018 for ampicillin (27% vs 47%;p=.014), piperacillin/tazobactam (55% vs 88%;p<.001), cefotaxime (59% vs 89%;p<.001), ciprofloxacin (71% vs 88%;p=.007), and trimethoprim-sulfamethoxazole (41% vs 69%;p=.001), but not significantly different for aminoglycosides and meropenem.In the SOT antibiogram of E. coli, decreased susceptibility trend was confirmed in some antibiotics, including piperacillin/tazobactam (83% in 2012-2013 vs 55% in 2017-2018). At our center, the solid organ transplant-specific antibiogram revealed important differences inE. colisusceptibilities and trends in antimicrobial resistance. Developing a SOT antibiogram will assist in revising and improving empiric treatment guidelines as well as monitoring antimicrobial resistance in this population.