Detection Of Carbapenem-resistant Enterobacteriaceae Research Articles

Raman spectrum combined with deep learning for precise recognition of Carbapenem-resistant Enterobacteriaceae.

Carbapenem-resistant Enterobacteriaceae (CRE) is a major pathogen that poses a serious threat to human health. Unfortunately, currently, there are no effective measures to curb its rapid development. To address this, an in-depth study on the surface-enhanced Raman spectroscopy (SERS) of 22 strains of 7 categories of CRE using a gold silver composite SERS substrate was conducted. The residual networks with an attention mechanism to classify the SERS spectrum from three perspectives (pathogenic bacteria type, enzyme-producing subtype, and sensitive antibiotic type) were performed. The results show that the SERS spectrum measured by the composite SERS substrate was repeatable and consistent. The SERS spectrum of CRE showed varying degrees of species differences, and the strain difference in theSERS spectrum of CRE was closely related to the type of enzyme-producingsubtype. The introduced attention mechanism improved the classification accuracy of the residual network (ResNet) model. The accuracy of CRE classification for different strains and enzyme-producing subtypes reached 94.0% and 96.13%, respectively. The accuracy of CRE classification by pathogen sensitive antibiotic combination reached 93.9%. This study is significant for guiding antibiotic use in CRE infection, as the sensitive antibiotic used in treatment can be predicted directly by measuring CRE spectra. Our study demonstrates the potential of combining SERS with deep learning algorithms to identify CRE without culture labels and classify its sensitive antibiotics. This approach provides a new idea for rapid and accurate clinical detection of CRE and has important significance for alleviating the rapid development of resistance to CRE.

Mortality Risk and the Clinical Outcome of Carbapenem-Resistant Enterobacteriaceae Carriers with Neutropenia: A Matched Case-Control Study

Patients with hematologic diseases are often accompanied by immunodeficiency, treatments as well as the disease itself can lead to granulocyte deficiency. Patients with granulocyte deficiency are under the high risk of infection. In recent years, the rate of Carbapenem-resistant Enterobacteriaceae (CRE) infection has gradually increased. Treatment options of CRE infection is limited, and effective anti-infection treatment is usually delayed, leading to the death of patients due to infection. CRE screening can provide clinical evidence for early detection of CRE by clinicians, thereby formulating antimicrobial treatment strategies. However, whether the initial empirical treatment covering CRE can improve the adverse outcomes of patients still lacks a definitive conclusion. We collected clinical data on patients with neutropenia who also undergoing CRE screening between January 2017 and December 2022. To further analyze the impact of CRE positivity on patient mortality risk and the clinical effectiveness of initial empirical treatment for CRE, we conducted two case-cohort studies with clinical baseline data matching. In total, we performed 3529 fecal CRE screenings from 664 patients. Out of these, 345 screenings from 135 patients tested positive for CRE. We identified 16 different strains, with the most common being Klebsiella pneumoniae (184/345), followed by Escherichia coli (76/345). To determine the influence of CRE positivity on patient mortality rates, we conducted a 1:2 case matching based on age, gender, diagnosis, and medical history of CRE-positive patients (Table 1). The results showed that in the overall analysis, CRE positivity, age over 60, and male gender were adverse factors influencing mortality. However, in the subgroup analysis of CRE-positive patients, no adverse factors affecting mortality were observed. To further assess the impact of CRE positivity on patient infection outcomes, we defined the initial antibiotic treatment strategies for a total of 4,872 infection events in screened patients. We divided them into the following groups: the empirical treatment group without CRE results (n=3,954), the empirical treatment group not covering CRE (n=122), and the CRE based empirical treatment group (n=796). The CRE based empirical treatment group had a higher success rate in initial empirical treatment compared to the group without covering CRE (65.5% vs. 59.0%). To further investigate the differences in initial empirical treatment success rates and 30-day mortality rates between patients in the CRE-based empirical treatment group and empirical treatment group without CRE covering, we performed 1:2 case matching for clinical baseline data on age, sex, diagnosis, past history, and disease status at infection according to the clinical characteristics of the CRE-based anti-infection treatment group. The results indicated that there were no significant differences in initial empirical treatment success rate and 30-day mortality rate between the CRE-based empirical treatment group and case-matched controls. In conclusion, diagnosing and treating patients with CRE infection presents significant challenges. Early screening for CRE and empirical treatment targeting CRE can increase the success rate of initial empirical treatment in CRE-positive patients.

Detection of carbapenem resistant enterobacteriaceae from various clinical samples: A record based study in a tertiary care hospital in Mandya

: Carbapenem Resistant Enterobacteriaceae (CRE) has gradually evolved as one of the serious global health concern due to its high mortality and limited treatment options. Overuse of the antibiotic and improper sanitation has led to its rapid spread. To determine the proportion of Carbapenem resistant Enterobacteriaceae from various clinical samples received in the Department of Microbiology, MIMS Mandya for Culture and sensitivity by using Meropenem and Imipenem disk.This is a retrospective study conducted over a period of 6 months from March 2021 to august 2021. The samples tested were all the clinical specimens like sputum, pus, urine, body fluids coming to our Microbiology laboratory. The specimens were processed by the standard laboratory methods. Bacteria was isolated and identified by standard biochemical reactions and antimicrobial susceptibility testing was done on Mueller Hinton Agar by Kirby Bauer disk diffusion method and interpreted according to CLSI guidelines.A total of 1624 samples were included in the study, among which 211 isolates were identified as members of Enterobacteriaceae family. 50 out of 211 isolates were confirmed as Carbapenem resistant giving a prevalence rate of 23.69%. Urine (42%) was the major contributor of CRE, followed by pus (34%). Among CRE, (54%) was the major organism isolated followed by (20%).Our study showed high CRE prevalence rate of 23.69%, indicating the rapid emergence of CRE. Hence, a strict adherence to antibiotic policy and basic infection control measures to be applied in view of reducing the spread of CRE in the community.

Active surveillance for carbapenem resistant enterobacteriaceae (CRE) using stool cultures as a method to decrease CRE infections in the pediatric intensive care unit (PICU)

BackgroundThe incidence of Carbapenem Resistant Enterobacteriaceae (CRE) infections is increasing worldwide. Due to dearth of alternative antibiotics, prevention of infection transmission is a part of CRE infection management strategy. Early detection of CRE by active surveillance coupled with contact isolation is much more appropriate compared to contact isolation upon receipt of routine cultures dictated by the patient's clinical condition. ObjectivesTo determine whether active CRE surveillance will decrease CRE infection rates in the Pediatric Intensive Care Unit (PICU). MethodsRetrospective observational study done in the 10-bed PICU of a tertiary care teaching children's hospital from July 2013 to June 2015. Rectal swabs for CRE were sent from all PICU patients except stable post-operative patients. Contact isolation precautions were followed for rectal swab positive patients. CRE colonization and infection rates were calculated and compared. ResultsTotal of 1262 rectal swabs were sent from 1022 patients. CRE colonization rate was 19.5%. Post intervention, ICU acquired CRE colonization decreased by 36% and ICU acquired CRE infection rates decreased by 100%, both showed significant decrease (p ​< ​0.0001). ConclusionActive CRE surveillance and institution of contact isolation in appropriate situations is helpful in decreasing CRE colonization and infection rates in the PICU.

Investigation and analysis of carbapenem-resistant gram-negative bacterial infection rates across hospitals in Shandong Province in China.

The increasing incidence of carbapenem-resistant bacterial infections has become a serious public health threat. This study aimed to investigate and analyze the current regional differences in carbapenem-resistant gram-negative bacteria (CRGN) in a major Province of China, and provide suggestions for preventing hospital infections. A questionnaire survey was used to obtain the current data on CRGN from 36 hospitals in Shandong Province, China, from 2019 to 2020. The association between the detection rates and discovery rates of CRGN and the use of antibacterial drugs was analyzed using Spearman's correlation coefficient. In addition, we compared the detection rates of CRGN and antibacterial drugs using hospitals categorized according to different levels and economic areas using the Kruskal-Wallis test. The average detection rates of CRGN across the 36 hospitals varied from 1.91% to 66.04%. The discovery rate of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-resistant Acinetobacter baumannii (CRAB) remained below 5‰, and that of carbapenem-resistant Pseudomonas aeruginosa (CRPA) was below 10‰. Except for CRAB, the correlations between the detection rate and antimicrobial drug use intensity and carbapenem drug use percentage were 0.11-0.29 and 0.31-0.47, respectively. Carbapenem drug use was higher in the provincial hospital group than in the prefecture-level hospitals (P < 0.05), and that in the high-economic regional hospital group was higher than in the low-economic regional hospital group (P < 0.05). The detection and discovery rates of CRE were low, and those of CRAB were high in Shandong Province. Larger hospitals have higher carbapenem drug use. These results can be used as a reference for preventing CRGN infections in developing countries and provide a basis for regional carbapenem resistance prevention and control strategies.

Detection of Carbapenem-resistant Enterobacteriaceae by Real-Time PCR and Assessment of Hospitalization Related Risk Factors Associated with their Fecal Carriage: A Case-control Study

Opportunistic behavior of commensal bacteria during severe infection, especially of the intestine is always considered as a predisposing threat for the severely ill patient admitted to hospitals. A descriptive-analytical case-control study was carried out to detect the prevalence and risk factor analysis of fecal carriage of Carbapenem-resistant Enterobacteriaceae. Patients having fecal carriage of Carbapenem-resistant Enterobacteriaceae were considered as cases and patients who were without Carbapenem-resistant Enterobacteriaceae were taken as the control in a proportion of 1:4. Carbapenem-resistant Enterobacteriaceae (CRE) was confirmed by both conventional as well as molecular methods. Methods such as Combined Disk Test, mCIMtest, and RAPIDEC CarbaNP Test were used for phenotypic identification of CRE, Whereas Real-Time (RT)-PCR was used for the detection of bla-gene encoded for CRE (blaNDM1, blaVIM, blaKPC, blaIMP, and blaOXA48). All patients belonging to medicine wards were included in the study. we screened 436 patients during the study and found 160 patients suitable for our study, out of which 32 (20%) were cases and 128 (80%) were controls. We found a total number of 25 genes out of 16 isolates, where NDM 1 was identified in maximum numbers followed by KPC &amp;VIM. Standard statistical analyses such as chi-squire and odd ratios were conducted to determine the risk factor of different variables. Stepwise multiple logistic regressions were carried out, where we found, that transfer from other wards to medicine ward, use of nebulizer and intravenous catheter, and use of multiple antibiotics were still statistically significant. Implementation of Multi-modal colonization prevention and control is the need for the present situation throughout the world.

An analysis of risk factors for carbapenem-resistant Enterobacteriaceae infection

This study aims to explore the high-risk factors of carbapenem-resistant Enterobacteriaceae (CRE) infection of hospitalised patients in high-risk departments. This study is a multicentre, retrospective study. CRE screening positive patients from 1 January 2016 to 31 December 2018 of high-risk departments in five tertiary first-class teaching hospitals in Beijing collect the patients' CRE test specimen information, CRE infection information and outcomes. The patients were divided into a colonisation group and an infection group for comparative analysis. A logistic regression model was established to explore the risk factors of CRE infection. Subgroup analysis was conducted according to invasive procedures and the type of the infection. In total, 344 patients were included in this study, including 85 (24.71%) colonisation and 259 (75.29%) infection; 36.09% CRE colonisation converted to infection, and the mean conversion time from colonisation to infection was 6.5 (4.0, 18.8) days. Renal disease, granulocytosis, invasive procedures and the time from hospital stay to positive CRE were the risk factors for CRE infection. The subgroup analysis showed that the rate of CRE infection in the invasive group was higher than in the non-invasive group (P < 0.001), and the rate of exacerbation or death in the invasive group was also higher than in the non-invasive group (P=0.019). The average length of ICU and hospitalisation in the healthcare-associated infection group were significantly higher than those in the community infection group, but there was no difference in the proportion of final exacerbation or death between them (P=0.727). Kidney disease, granulocytosis, invasive procedures and CRE detection time are the risk factors for CRE infection. Carrying out CRE screening in patients as early as possible and taking effective intervention measures in time to avoid adverse consequences is all important.

Association between tocilizumab and emerging multidrug-resistant organisms in critically ill patients with COVID-19: A multicenter, retrospective cohort study

BackgroundTocilizumab is an IgG1 class recombinant humanized monoclonal antibody that directly inhibits the IL-6 receptor. Several randomized clinical trials have evaluated its safety and efficacy in patients with coronavirus disease 2019 (COVID-19), and these studies demonstrate conflicting results. Our study aimed to determine the association between tocilizumab treatment and microbial isolation and emergence of multidrug-resistant bacteria in critically ill patients with COVID-19.MethodsA multicenter retrospective cohort study was conducted at two tertiary government hospitals in Saudi Arabia. All critically ill patients admitted to intensive care units with a positive COVID-19 PCR test between March 1 and December 31, 2020, who met study criteria were included. Patients who received tocilizumab were compared to those who did not receive it.ResultsA total of 738 patients who met our inclusion criteria were included in the analysis. Of these, 262 (35.5%) received tocilizumab, and 476 (64.5%) were included in the control group. Patients who received tocilizumab had higher odds for microbial isolation (OR 1.34; 95% CI 0.91–1.94, p = 0.13); however, the difference was not statistically significant. Development of resistant organisms (OR 1.00; 95% CI 0.51–1.98, p = 0.99) or detection of carbapenem-resistant Enterobacteriaceae (CRE) (OR 0.67; 95% CI 0.29–1.54, p = 0.34) was not statistically significant between the two groups.ConclusionsTocilizumab use in critically ill patients with COVID-19 is not associated with higher microbial isolation, the emergence of resistant organisms, or the detection of CRE organisms.

Comparative Study on DNA Amplification Methods for Detection of Carbapenem-Resistant Enterobacteriaceae (CRE)

Background: Carbapenem-resistant Enterobacteriaceae (CRE) is a resistant group of gram-negative bacteria that produces carbapenemase destroying carbapenem molecules causing drug resistances. Among them, the incidence of New Delhi metallo-beta-lactamases (blaNDM-1), a metallocarbapenemases or class B carbapenemases or metallo-β-lactamases (MBL), are increasing worldwide. Objective: To focused on comparative study on DNA amplification methods for detection of CRE in terms of analytical sensitivity and specificity. Materials and Methods: CRE strains (Escherichia coli, Escherichia cloacae, Citrobacter freudii, and Klebsiella pneumonia) were collected from HRH Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand. All specimens were initially screened for CRE isolates by using carbapenem disks inhibition test. The polymerase chain reaction (PCR), loop mediated isothermal amplification (LAMP) and recombinant polymerase amplification (RPA) assays were further employed for identification of drug resistance blaNDM-1 gene among CRE isolates. The analytical sensitivity and specificity of the three amplification assays were compared and analyzed. Results: The analytical sensitivity test of PCR, LAMP and RPA assays revealed that the limit of detection were 0.74 ng/μL, 7.4 pg/μL, and 0.74 ng/μL, respectively. Specificity test demonstrated that all three assays showed no cross hybridization to the other 15 related bacterial isolates. Conclusion: The data pointed out that LAMP assay was 100 times more sensitive than PCR and RPA, which could be suitable for application as early detection test for carbapenem resistant bacteria. Hence, the physician can select the proper antibiotics to treat the CRE infectious bacteria, which can reduce morbidity and mortality rates in patients. In the future, LAMP will be combined with lateral flow dipstick (LFD) to improve the efficacy of the assay as not only the early detection test with high sensitivity and specificity for carbapenem resistant bacteria, but also as the convenient and rapid screening test. Keywords: Enterobacteriaceae; Carbapenem; Carbapenem-resistant Enterobacteriaceae (CRE); New Delhi metallo-beta-lactamase (blaNDM-1)

Global trends and hotspots in research of carbapenem-resistant Enterobacteriaceae (CRE): a bibliometric analysis from 2010 to 2020.

Infectious disease caused by carbapenem-resistant Enterobacteriaceae (CRE) has become one of the most serious challenges due to its high morbidity and mortality and research on it has aroused great concern worldwide in the last decade. Thus, a bibliometric analysis of relevant publications is needed to identify the situation of current investigations and prioritize the future research areas. The current study retrieved articles related to CRE published between 2010 and 2020 from the Web of Science core collection database. The search strategy syntax included "carbapenem-resistant Enterobacteriaceae", "carbapenem-resistant Klebsiella pneumoniae", "carbapenemase producing Enterobacteriaceae" and "carbapenemase producing Klebsiella pneumoniae" which were searched in both Medical Subject Headings (MeSH) and titles. A bibliometric analysis was conducted using VOSviewer, Bibliographic Item Co-Occurrence Matrix Builder, gCLUTO and other machine learning tools. Key words, subject terms, contributions as well as collaborations were assessed. Moreover, hot off the press and future research trends were demonstrated. A total of 1,671 publications on CRE were finally included in the bibliometric analysis and 5 related theme clusters were identified which mainly focused on epidemiology, resistance mechanisms, antibiotics treatment and infection control. A total of 142 keywords occurred more than 5 times and the most frequent keyword was "carbapenem-resistant Enterobacteriaceae" with 247 occurrences and a total link strength of 559. The output on CRE has gradually increased during the last decade, and the USA has made the greatest contribution due to the 533 research papers. Agents that act against CRE, especially ceftazidime-avibactam (occurrences, 85; average publication year, 2018.26), and the early detection of CRE by genome sequencing techniques (occurrences, 97; average publication year, 2017.94) were emerging hot topics which would probably attract future research interest. The bibliometric analysis revealed that development of antibacterial agents, early etiological detection and genome sequencing techniques were the hotspots and would probably direct the future research directions which would also facilitate a better understanding of the epidemiology of drug-resistant bacteria and implementing the antibiotic stewardship program.

Multi-faceted strategies improve collection compliance and sample acceptance rate for carbapenem-resistant Enterobacteriaceae (CRE) active surveillance testing

Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center. Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated. Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%. Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.

English

BACKGROUND In an infection caused by multidrug-resistant Enterobacteriaceae, carbapenems is one the last antibiotics used, but the carbapenemase producing Enterobacteriaceae pose a clinical challenge. A relatively new test which was described few years back known as modified carbapenem inactivation method (mCIM) is used to detect the presence of carbapenemase activity in Gramnegative bacilli. Various studies show this test be to be very sensitive and specific. We aim to study mCIM positivity on samples which are positive by Kirby-Bauer disk diffusion antibiotic sensitivity test method used for detection of carbapenem resistant Enterobacteriaceae (CRE) from clinical specimens. METHODS The study is a cross sectional descriptive study conducted in a tertiary care hospital. Samples received from February 2019 to September 2019 were included in the study. During this period 150 samples were collected which were resistant to meropenem by Kirby-Bauer disk diffusion method. These CREs isolates were further subjected to mCIM and the result was analysed. RESULTS Out of the total 150 CRE isolates which were 100 % resistant to meropenem by the conventional disc diffusion method it is found that mCIM was positive for 148 (98.66 %) isolates and negative for only 02 (1.33 %). Two most common CRE were Klebsiella pneumonia (58 %) and Escherichia coli (32 %). In statistical analysis chi square test revealed statistically significant difference (P &lt; 0.05) in percentage of positivity between the two methods (98.66 % vs 100 %). CONCLUSIONS mCIM is highly sensitive and specific method; however, in practice it showed no added advantage over Kirby-Bauer disk diffusion method in detecting CRE. KEYWORDS Modified Carbapenem Inactivation Method (mCIM), Kirby-Bauer Disk Diffusion Method, Carbapenem Resistant Enterobacteriaceae

Companion Animals Emerged as an Important Reservoir of Carbapenem-Resistant Enterobacteriaceae: A Report from India.

The emergence and spread of carbapenem-resistant Enterobacteriaceae (CRE) are perceived as a serious public-health threat world-wide. Despite sporadic reports, no systemic study has been carried out on CRE in companion animalsin Indian subcontinent. In total, 237 canine specimens collected from five veterinary polyclinics in and around Kolkata were analyzed for isolation, antimicrobial resistance profiling and molecular characterization of carbapenem-resistant (CR) E. coli. Of the 29 CR isolates, 19 were identified as metallo-β-lactamase producers (MP-CRE) and 10 as metallo-β-lactamase non-producers (MNP-CRE). Eleven of them were extended spectrum β-lactamase and/or AmpC type β-lactamase producers and harboured fluoroquinolone-, tetracycline-, sulfonamide- and aminoglycoside-resistant genes. Beside uropathogenic virulence determinants, they carried the adhesion factors mediating biofilm production which was remarkably higher in 6 MP-CRE and one MNP-CRE isolates. Although the CRE were of diverse origin including the healthyand the diseased dogs, these were more frequently isolated from canine pyometra. The MP-CRE harboured plasmids of IncF and IncA/C types. Phylo-type B1 was observed in38% of the CR isolates, followed by A0 in31% and rest were attributed to A1 and D1. The Enterobacterial repetitive intergenic consensus-PCR (ERIC-PCR) revealed that these isolates were genetically diverse and constituted of a heterogenous population. Detection of CRE in pet dogs despite the fact that carbapenems are not used in animals in India emphasizes the need for active surveillance to identify the transmission and dynamics of such pathogens in companion animals.

Epidemiology, risk factors and molecular analysis of carbapenem-resistant Enterobacteriaceae (CRE) in Mthatha, Eastern Cape, South Africa

Background: The emergence of carbapenem resistance in Enterobacteriaceae is an important threat to global health. Reported outcomes of infections with carbapenem-resistant Enterobacteriaceae (CRE) are poor. Commonly used antibiotics are generally inactive against CRE. Therefore, timely detection of CRE is of paramount importance. This study aimed to investigate the resistance genes responsible for CRE in Mthatha and to identify risk factors. Methods and materials: Study design – Prospective cohort study. Study period – 23 April to 27 September 2019. Setting – Eastern Cape province, SA. Study population – All adult and paediatric CRE patients. CRE case definition according to CDC 2018. ID and AST-bioMérieux Vitek 2 system. Detection of the blaOXA-48, blaKPC, blaNDM, and blaVIM by the RESIST-4 OKNV assay (Coris). Patients were interviewed to determine risk factors associated with CRE. Results: Forty-four non-duplicate CRE patients were identified during the study period from microbiology lab at NMAH. Enterobacteriaceae species: K. pneumoniae 22 (61.4%), E. cloacae 10 (22.7%), E. coli 2 (4.5%) and K. oxytoca, P. rettgeri and M. morganii 1 each (4.3%). Adult patient 29 (65.9%0 and paediatric 15 (34.1%). Race: all black patients except one white. CRE genes-blaOXA-48 22 (50%), blaNDM 8 (18.2%), two isolates (4.5%) with both blaOXA and blaNDM. We did not find any blaKPC and blaVIM in our setting and 12 (27.2%) isolates were negative for all OKNV. Outcomes: Demised 18 (40.9%), still admitted in the ward 1 (2.3%), discharged home on basis of clinical grounds 22 (50%) and 3 (6.8%) were transferred back to the district hospitals. HAI in 27 (61.4%) with VAP 8, HABSI 8, CAUTI 5, SSI 3 and CLABSI in 3. Risk factors for CRE acquisition were antibiotic exposure 25 (58.7%), ICU stay 7 (15.9%), received medical care in last 6 months 35 (79.6%) and none travelled outside RSA. HIV positive – 19 (43.2%). Conclusion: In out setting our CRE mortality rate is 40.9%, common CRE genotypes are blaOXA-48 and blaNDM. K. pneumoniae is the most common CRE-producing Enterobacteriaceae and antibiotic exposure is an important risk factor in Mthatha and surrounding areas.

Assessment of carbapenem-resistant Enterobacteriaceae-plate formula and quality control procedure.

AimsTo assess a cost‐effective in‐house selective plate formula for actively screening carbapenem‐resistant Enterobacteriaceae (CRE).Methodology and resultsThe in‐house formula included CHROMagarTM Orientation, meropenem, and ingredients present in the Mac‐Conkey formula, such as bile salts and crystal violet (pH 6.9‐7.2). American Type Culture Collection strains and 200 clinical strains were used to validate the plate formula. The CRE plates had a sensitivity of 97.4% and a specificity of 98.8% with ATCC andor clinical strains used in the quality control procedure. A point prevalence survey among the 18 inpatients at Viet‐Tiep hospital ICU using fecal swabs plated at the in‐house agar plate showed a CRE prevalence of 44.4%.ConclusionThe in‐house plate had high sensitivity and specificity, particularly for Escherichia coli and the KESC group (Klebsiella spp., Enterobacter spp., Serratia marscescens, and Citrobacter spp.), and it may be widely applied as an alternative to other ready‐to‐use commercial plates.Significance and impact of the studyThe formula developed in the present study may facilitate the early detection and isolation of CRE and decrease transmission, particularly in low‐ and middle‐income countries with a high rate of CRE colonization and limited access to ready‐to‐use commercial plates.

Emergence of Carbapenem-Resistant Enterobacteriaceae in a Tertiary Care Hospital in Southern Thailand†

Carbapenem-resistant Enterobacteriaceae (CRE) is emerging as a major problem in healthcare settings globally, including Thailand, due to limited therapeutic options. We reported the detection, antimicrobial susceptibility profiles, and the presence of carbapenemase genes of CRE isolates obtained from Songklanagarind Hospital between July 2012 and June 2015. A total of 273 non-duplicated CRE isolates was recovered from 248 patients. The predominant organism was Klebsiella pneumoniae (183 [67.0 %]), followed by Escherichia coli (38 [13.9 %]). The susceptibility to 13 antibiotics was performed by disk diffusion assay. Most of the CRE isolates remained susceptible to amikacin. Minimum inhibitory concentrations (MIC) of carbapenems were determined by E-test. The MIC50 and MIC90 were varied among genera and species. Multiplex PCRs for the carbapenemase genes blaIMP, blaVIM, blaOXA-48, blaNDM-1, blaKPC, and blaGES were performed. One hundred and seventy-eight out of these 273 CRE isolates (65.2 %) harbored either single or multiple carbapenemase genes. One hundred and fifty nine isolates harbored the blaNDM-1 gene (113 K. pneumoniae, 25 E. coli, 17 E. cloacae, 2 Citrobacter freundii, 1 Enterobacter aerogenes, and 1 Pantoea agglomerans), 7 isolates carried blaIMP (4 K. pneumoniae, 2 C. freundii, and 1 E. cloacae), 7 isolates possessed blaOXA-48 (1 K. pneumoniae, 5 E. coli, and 1 E. aerogenes), whereas 3 and 2 isolates harbored blaNDM-1 and blaIMP (2 K. pneumoniae and 1 E. cloacae) and blaNDM-1 and blaOXA-48 (1 E. coli and 1 E. cloacae), respectively. In conclusion, this study revealed the detection of CRE, with the majority of K. pneumoniae harboring blaNDM-1 in this setting.

Changing US Epidemiology of NDM-Producing Carbapenem-Resistant Enterobacteriaceae, 2017–2019

Background: Due to limited therapeutic options and potential for spread, carbapenem-resistant Enterobacteriaceae (CRE)-producing New Delhi metallo-β-lactamases (NDMs) are a public health priority. We investigated the epidemiology of NDM-producing CRE reported to the CDC to clarify its distribution and relative prevalence. Methods: The CDC’s Antibiotic Resistance Laboratory Network supports molecular testing of CRE for 5 carbapenemases nationally. Although KPC is the most common carbapenemase in the United States, non-KPC carbapenemases are a growing concern. We analyzed CRE with any of 4 non-KPC plasmid-mediated carbapenemases (NDM, VIM, IMP, or OXA-48 type) isolated from specimens collected from January 1, 2017, through June 30, 2019; only a patient’s first isolate per organism–carbapenemase combination was included. We excluded isolates from specimen sources associated with colonization screening (eg, perirectal). We compared the proportion of NDM-producing CRE to all non-KPC–producing CP-CRE between period A (January to June 2018) and period B (January to June 2019). Health departments and the CDC collected additional exposure and molecular information in selected states to better describe current NDM-producing CRE epidemiology. Results: Overall, 47 states reported 1,013 non–KPC-producing CP-CRE (range/state, 1–109 isolates; median, 11 isolates); 46 states reported 631 NDM-producing CRE (range/state, 1–84; median, 6). NDM-producing CRE increased quarterly from the third quarter of 2018 through the second quarter of 2019; CP-CRE isolates with other non-KPC carbapenemases remained stable (Fig. 1). In period A, 124 of 216 emerging CP-CRE had NDM (57.1%), compared with 255 of 359 emerging CP-CRE (71.0%) during period B (P = .1179). Among NDM-producing CRE, the proportion of Enterobacter spp increased from 10.5% in 2018 to 18.4% in 2019 (P = .0467) (Fig. 2). In total, 18 states reported more NDM-producing CRE in the first 6 months of 2019 than in all of 2018. Connecticut, Ohio, and Oregon were among states that conducted detailed investigations; these 3 states identified 24 NDM-producing CRE isolates from 23 patients in period B. Overall, 5 (21.7%) of 22 patients with history available traveled internationally ≤12 months prior to culture; 17 (73.9%) acquired NDM-producing CRE domestically. Among 15 isolates sequenced, 8 (53.3%) carried NDM-5 (6 E. coli, 1 Enterobacter spp and 1 Klebsiella spp) and 7 (46.7%) carried NDM-1 (6 Enterobacter spp and 1 Klebsiella spp). Species were diverse; no single strain type was shared by &gt;2 isolates. Conclusions: Detection of NDM-producing CRE has increased across the AR Lab Network. Among states with detailed information available, domestic acquisition was common, and no single variant or strain predominated. Aggressive public health response and further understanding of current US NDM-CRE epidemiology are needed to prevent further spread.Disclosures: NoneFunding: None

1177 QUANTITATIVE QPCR-BASED BIOBURDEN TEST FOR THE DETECTION OF CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE): NOVEL TEST FOR SURVEILLANCE AND RISK-STRATIFICATION

Current strategies to combat duodenoscope-associated carbapenem-resistant Enterobacteriaceae (CRE) transmission, a low-prevalence but high-risk clinical problem, are either capital intensive (ethylene oxide sterilization) or time- and resource-intensive (reference laboratory PCR or culture and sequester strategy). PCR tests do not discriminate live vs. dead organisms and quantify them. Our aim was to develop and perform initial analytical verification and clinical sample testing of a bioburden qPCR test that quantifies the number of live CRE present on duodenoscopes or biofluids within 3 hours of sampling. We designed TaqMan assays against each intended target gene sequences (16S rRNA, Klebsiella pneumonia carbapenemase (KPC) and New Delhi metallo β-lactamase (NDM)) that can detect and quantify genomic DNA (gDNA) across 5-9 log concentrations with >95% qPCR amplification efficiency. We developed an optimum gDNA extraction method to extract gDNA with maximum efficiency. Propidium monoazide (PMA)/ enhancer concentrations and incubation/light exposure time was optimized to yield maximum cycle threshold (Ct) difference in qPCR quantification between live and dead CRE (Figure. 1). We successfully tested and quantified live CRE from serial dilutions of intentionally spiked (with different CRE concentrations) patient-derived bio-fluids (bile and gastrointestinal secretions) acquired during ERCPs (n=15). Duodenoscope samples were collected by flushing 10 ml of sterile saline through the accessory channel and dipping and agitating the end of the duodenoscope and performing ten up and down movements of the elevator in a container of sterile saline Propidium monoazide (PMA)/enhancer can detect, differentiate and quantitate 10% of spiked-in live bacteria among the dead. Our DNA extraction method outperforms commercially available DNA extraction kits that we tested, in time, cost and efficiency. Assay reproducibly detects >100 intentionally spiked NDM1+ and KPC1+ CFUs either within patient derived biofluids or endoscope wash fluids (Saline) (figure 2). There is no detectable PCR inhibition from patient derived abdominal fluids, and biliary specimens. We report on the successful development and initial testing of a rapid-turnaround quantitative PCR bioburden test that can detect and quantify small numbers of live CRE on duodenoscopes and biofluids. Experiments are underway to test the accuracy, precision, and the analytical sensitivity of the assay. Future studies will include test validation in a multi-center duodenoscope and other medical device-derived biofluid testing and creation of a digital PCR interface.Figure 2Amplification plot demonstrating detection of live CRE among intentionally spiked biofluids.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Detection of antimicrobial resistance genes of carbapenem-resistant Enterobacteriaceae in Escherichia coli isolated from the water supply of smallholder dairy farms in Saraburi and Maha Sarakham, Thailand

Background and Aim: The problem of antimicrobial resistance of bacteria in both humans and animals is an important public health concern globally, which is likely to increase, including in Thailand, where carbapenem-resistant Enterobacteriaceae (CRE), such as Escherichia coli, are of particular concern. They are pathogens found in the gastrointestinal tract of humans and other animals as well as in the environment. They may cause opportunistic infection and are often resistant to antibiotics in various fields especially in animal husbandry, such as pets or livestock farms. This study aimed to investigate the occurrence of carbapenem-resistant E. coli from water samples of smallholder dairy farms in Saraburi and Maha Sarakham, Thailand. Materials and Methods: Sixty-four water samples were collected from 32 dairy farms in Kaeng Khoi district, Muak Lek district, and Wang Muang district of Saraburi Province, and Kantharawichai district and Mueang district of Maha Sarakham Province, Thailand. All samples were cultured and isolated for E. coli by biochemical tests. All E. coli isolates were tested for drug susceptibility using imipenem, meropenem, and drug resistance genes of carbapenemases such as blaNDM, blaIMP, and blaOXA48 of drug-resistant E. coli isolates detected by polymerase chain reaction (PCR) technique. Results: A total of 182 E. coli isolates were found (140 and 42 isolates from Saraburi and Maha Sarakham, respectively). Drug sensitivity tests found that two isolates of E. coli from water in Kaeng Khoi were resistant to imipenem; therefore, the incidence of E. coli resistance to carbapenem was 1.43% of Saraburi Province. On the other hand, there was no incidence of drug-resistant E. coli in Maha Sarakham. In addition, the detection of the drug-resistant gene of E. coli in both isolates by PCR showed the expression of blaNDM. Conclusion: This study reports E. coli resistance to antimicrobial drugs on livestock farms. It can be considered to be the first report of E. coli CRE detection in a dairy farm at Saraburi, which should be the subject of further extended study.

Genomic characterization of an emerging blaKPC-2 carrying Enterobacteriaceae clinical isolates in Thailand

The rapidly increasing prevalence of carbapenem-resistant Enterobacteriaceae (CRE) over the past decade has increased concern in healthcare facilities and the impact on public health. The prevalence of blaKPC (KPC) in Thailand remains very low; only blaKPC-13 has been described previously. This study is the first to describe the characteristics of blaKPC-2-carrying Klebsiella pneumoniae, Escherichia coli, and Enterobacter asburiae in Thailand. The prevalence rate of blaKPC-2-carrying isolates was 0.13% among CRE isolates in our study. Based on carbapenem susceptibility testing, K. pneumoniae C1985 was resistant to meropenem and ertapenem, E. coli C1992 was resistant to meropenem, imipenem, and ertapenem, and E. asburiae C2135 was only resistant to imipenem. K. pneumoniae C1985 carried blaKPC-2, blaSHV-11, fosA, oqxA, and oqxB, while E. coli C1992 contained blaKPC-2 and mdf(A) and E. asburiae C2135 harbored blaKPC-2, blaACT-2, and qnrE1. The genetic features of blaKPC-2 in the 3 isolates revealed identical rearrangement and flanking regions. Analysis of genomic sequences from these 3 isolates revealed that the sequence types of K. pneumoniae C1985, E. coli C1992, and E. asburiae C2135 were ST4008, ST7297, and ST1249, respectively. The 3 blaKPC-2 isolates were from individual living cases. Two cases were colonization for K. pneumoniae C1985 and E. asburiae C2135 and the third case was hospital-acquired infection of E. coli C1992. Although the prevalence of blaKPC-2-carrying CRE is relatively low in this study, continued surveillance and close monitoring are warranted. In addition, prompt or early detection of CRE and strict implementation of infection control are essential to prevent outbreaks or rapid spread in hospitals.