Multidrug-resistant Organisms Research Articles

Home-based nursing care for clients carrying multidrug-resistant organisms: a focus group study

Abstract Background The growing population of vulnerable clients receiving home-based nursing care, combined with the worldwide increase in the prevalence of multidrug-resistant organisms (MDROs), poses a new burden on nursing staff. This study aimed to gain insight into the experiences, attitudes, perceptions, dilemmas in daily practice and needs of nursing staff providing home-based nursing care for clients carrying MDROs. Methods Seven focus group discussions with home-based nursing staff (N = 34) were performed in the Netherlands between April and July 2022, using a semi-structured, open-ended topic list based on the I-change model and seven domains synthesized by Flottorp et al. Data were analysed using thematic analysis. Results Home-based nursing staff often considered infection prevention and control recommendations inconsistent, unclear or inapplicable in daily practice. Although participants acknowledged the importance of these precaution measures, their proportionality was sometimes questioned. Participants indicated to be influenced by perceptions, knowledge and behaviour of their colleagues and clients. In addition, they frequently experienced untimely, incomplete or inconspicuous information transfers about clients carrying MDROs. Concerns were expressed that clients were often insufficiently informed, debating the roles and responsibilities of involved healthcare professionals in providing and exchanging information. Finally, participants elaborated on the effect of the covid-19 pandemic and expressed the need for organisational support in providing education and sufficient resources regarding MDROs. Conclusions Insights of this study have aided in aligning upcoming MDRO guidelines for home-based nursing care in the Netherlands. Organisational support in expanding knowledge and providing sufficient resources is essential and clarity about roles and responsibilities of involved healthcare professionals regarding information transfer and informing patients is needed. Key messages • Expanding knowledge, sufficient resources and adequate information transfer about MDRO carriage are essential to ultimately prevent transmission and spread of MDROs. • The specific context of home-based nursing care for clients carrying MDROs should be acknowledged in MDRO guidelines.

Home-based nursing care: what do we know about multidrug-resistant organisms in this setting?

Abstract Background The burden and complexity of home-based nursing care have intensified due to earlier discharges from hospitals and patients living longer at home with increasing co-morbidities. This growing population of vulnerable patients, combined with the worldwide increase in the prevalence of multidrug-resistant organisms (MDROs), poses a new burden on home-based nursing staff. Home-based nursing care differs significantly from hospitals and nursing homes, challenging implementation of infection prevention and control (IPC) measures. It is therefore important to gain insight into the attitudes, experiences and needs of home-based nursing staff. Also, to better understand the scope of MDRO carriage and transmission in this setting, including its challenges. Methods Cross-sectional studies were conducted in the Netherlands including a survey and focusgroup study among home-based nursing staff, supplemented by a report of cases of MDRO clusters. Results We have identified several factors adding to the complexity of responding to an MDRO outbreak with involvement of home-based nursing care. First, inapplicable recommendations in guidelines/protocols or from infection preventionists, often aimed at intramural care. Second, nursing staff questioned the proportionality of IPC measures, potentially influenced by behaviour of colleagues and patients. Third, inadequate information transfers about patients carrying MDROs. Fourth, uncertainty about the roles and responsibilities of involved healthcare professionals. Finally, the need for organisational support in providing education and sufficient resources, and clarity about financial aspects. Conclusions Insights from these studies have aided in aligning upcoming MDRO guidelines for home-based nursing care in the Netherlands, which factor in the above mentioned complexity. Furthermore, these findings can aid in future strategies to prevent or respond early in MDRO outbreaks with involvement of home-based nursing care.

4.C. Scientific session: Navigating through complex challenges of responding to outbreaks of multidrug-resistant organisms

Abstract Antimicrobial resistance is one of the top ten global public health threats according to the WHO, contributing to millions of deaths each year. While outbreaks of multidrug-resistant organisms (MDROs) are well studied in hospital and nursing home settings, knowledge gaps exist concerning the complex challenges of outbreaks of MDROs among vulnerable patient populations, such as patients with intellectual disabilities or elderly patients living longer at home with multiple comorbidities. The coordination of such outbreaks requires a multidisciplinary approach as these patients often receive care throughout different healthcare settings, including long-term care and home-based nursing care. We delve into the complexities of coordinating an MDRO outbreak response involving healthcare professionals from various healthcare settings. The challenges inherent to the coordination of multidisciplinary involvement and the use of innovative strategies for outbreak preparedness and surveillance, will be thoroughly examined based on scientific evidence and practice based experiences. Workshop objectives • To exchange experiences on managing cross-institutional outbreaks of MDROs • To foster deeper understanding of the complexities of multidisciplinary involvement during MDRO outbreaks among vulnerable patient populations The workshop structure: - A brief introduction will be provided on the generic challenges in providing long-term care to vulnerable patient populations carrying MDROs. We will subsequently illustrate potential challenges faced during a cross-institutional MDRO outbreak among these patients through a realistic scenario (5 min): A patient with severe intellectual and physical disabilities living in both a long-term care facility as well as with family at home, unexpectedly turns out to be carrying an MDRO after recent hospital admission. As the patient receives nursing care from both from family members and nursing staff in different healthcare settings, a cross-institutional MDRO outbreak has occurred requiring a coordinated response. - Hereafter, individual presenters will address evidence- and experience-based challenges faced in MDRO outbreak responses within the specific healthcare settings covered in the previously presented scenario. We will navigate through the scenario together with the participants, discussing practical and ethical dilemmas, and explore ways for containing the MDRO outbreak while maintaining effective and compassionate healthcare delivery. In addition, we will discuss the use of public health innovations, such as social network analysis as a basis for the development of a stress test exercise to improve preparedness for MDRO outbreaks, and the role of wastewater surveillance in MDRO outbreaks. Discussions will be facilitated by (online) voting tools to invite participants to exchange experiences (40 min). We conclude with an exciting quiz to summarize the key messages of this workshop (10 min). Key messages • Healthcare setting, knowledge, proportionality and well-being of vulnerable patients populations are important to acknowledge during cross-institutional MDRO outbreaks. • Novel stress test exercise and wastewater surveillance are potential methods to improve preparedness and surveillance, respectively, during cross-institutional MDRO outbreak responses.

Long-term care facilities: what do we know about multidrug-resistant organisms in this setting?

Abstract Background People with intellectual disabilities (ID) are an often overlooked high-risk group for health-related issues. In the Netherlands, people with ID may reside at home, in small communities, or within long-term care facilities. This diverse living arrangement challenges the healthcare system, with responsibilities spread among multiple formal and informal caregivers. During an outbreak with multidrug-resistant organisms (MDROs), coordinated efforts should be made to prevent further spread throughout all healthcare settings. Therefore, adequate infection prevention and control (IPC) practices, are required to improve or maintain individual health outcomes. To understand the complexity of MDROs in long-term care for people with ID, it is important to gain insight into knowledge, attitudes and perceptions of involved healthcare professionals and, investigate innovative strategies that could play a role in surveillance or monitoring an outbreak within this setting. Methods We conduct several studies in long-term care for people with ID, using a wide scale of methodologies including a cross-sectional survey study and innovative quantitative methods, such as wastewater surveillance. Results We have identified several challenges in long-term care for people with ID related to IPC and MDROs. First, while IPC and MDRO guidelines exist, they lack specific context and applicability to the long-term care setting. Second, proper use of hand gloves among healthcare professionals demands increased attention as knowledge about this preventive measure seems to be insufficient. Finally, given the challenges in sample collection for MDRO screening, non-invasive strategies are needed to offer insight during outbreaks, serving surveillance or outbreak management purposes. Conclusions Insights from these studies could inform future strategies to prevent or respond early in case of an MDRO outbreak within long-term care for people with ID.

Preparedness for and collaboration during regional outbreaks with multidrug-resistant organisms

Abstract Background Outbreaks with multidrug-resistant organisms (MDROs) are a significant burden on the healthcare system and the wellbeing of affected patients and carriers. Cross-institutional MDRO outbreaks require a concerted multidisciplinary effort for effective outbreak management. This presents challenges regarding cooperation, coordination and communication between stakeholders. In this study, we investigate collaborative structures and coordination roles in Dutch outbreak response networks and how Dutch healthcare professionals engage in preparedness activities relating to MDRO outbreaks. These findings form the basis for the development of a stress test exercise for improving professional and organizational collaboration and coordination during MDRO outbreaks. Methods Using a mixed-methods design, an online survey and qualitative interviews are conducted among healthcare professionals in two healthcare regions in the Netherlands. Social network analysis is used to gain insight in collaborative structures and brokerage roles. To investigate preparedness activities, the survey is combined with qualitative interviews to explore respondents’ experiences, preferences and needs regarding preparedness activities for MDRO outbreak management. Results During the workshop we will show the cross-organizational network structures, the strengths and weakness of the mutual connections and provide insight in positions in networks, roles and responsibilities. Also, we provide insight in how the use of and experience with training and exercise activities, such as stress tests, contribute to preparedness for MDRO outbreaks in vulnerable patient populations. Conclusions This study shows how healthcare professionals from different organizations collaborate during MDRO outbreaks, and how they engage with preparedness activities. This provides valuable input for development of a stress test specific to MDRO outbreak management, and other interventions to improve outbreak preparedness.

Impact of Exogenous Lactiplantibacillus plantarum on the Gut Microbiome of Hematopoietic Stem Cell Transplantation Patients Colonized by Multidrug-Resistant Bacteria: An Observational Study

Background: Lactiplantibacillus plantarum can inhibit the growth of multidrug-resistant organisms (MDROs) and modulate the gut microbiome. However, data on hematopoietic stem cell transplantation (HSCT) are scarce. Aim: In an observational study, we assessed the impact of L. plantarum on the modulation of the gut microbiome in HSCT patients colonized by MDROs. Methods: Participants were allocated to an intervention group (IG = 22) who received capsules of L. plantarum (5 × 109 CFU) twice per day until the onset of neutropenia or a control group (CG = 20). The V4 region of the 16S bacterial rRNA gene was sequenced in 87 stool samples from a subset of 33 patients (IG = 20 and CG = 13). The Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt2) program was used to predict metagenome functions. Results: L. plantarum demonstrated an average 86% (±11%) drug-target engagement at 43 (±29) days of consumption and was deemed safe, well-tolerated, and associated with an increase in the abundance of the Lactobacillales (p < 0.05). A significant increase in Lactococcus and a reduction in Turicibacter (p < 0.05) were identified on the second week of L. plantarum use. Although Enterococcus abundance had a greater rise in the CG (p = 0.07), there were no significant differences concerning the Gram-negative MDROs. No serious adverse effects were reported in the IG. We observed a greater, non-significant pyruvate fermentation to propanoate I (p = 0.193) relative abundance in the IG compared with the CG. L. plantarum use was safe and tolerable by HSCT patients. Conclusions: While L. plantarum is safe and may impact Enterococcus and Turicibacter abundance, it showed no impact on Gram-negative MDRO abundance in HSCT patients.

Resistance Profiles of the ESKAPEE Complex at Veracruz’ s Children Hospital, 2023

Abstract Introduction ESPAKEE complex bacteria are well known as a Multidrug Resistance Organisms that cause difficult mange infections. Management of these infections should be based on the monitoring of resistance profiles to provide appropriate therapy to reduce hospitalization costs and patient improvement. Materials and methods A cross-sectional, retrospective, descriptive study analyzed 179 ESKAPEE bacteria isolated from pediatric patients (0-18 years) between January 1 and December 31, 2023. Laboratory tests utilized VITEK 2.0 technology, reporting Minimal Inhibitory Concentration (MIC) and classifying them as resistant or non-resistant. Descriptive statistics were generated using SPSS v22. Results The study included 179 antibiograms. Among Enterobacter species, E. aerogenes (3) and E. cloacae (17) showed 100% resistance to cefalotin. S. aureus (22) exhibited the highest resistance to Oxacillin (36.4%). Klebsiella pneumoniae (40) demonstrated 97.5% resistance to Ampicillin, followed by resistance to first-generation cephalosporins: cefalotin 62.5%, and third-generation cephalosporins: ceftriaxone and ceftazidime both at 60%. Acinetobacter baumannii (9) showed 100% resistance to Fosfomycin. Pseudomonas aeruginosa (30) displayed 100% resistance to Ceftriaxone, Cefotaxime, and Cefuroxime. Enterococcus faecium (2) exhibited 100% resistance to ciprofloxacin, erythromycin, ampicillin, and levofloxacin, while Enterococcus faecalis (16) showed 50% resistance to tetracycline. E. coli (39) exhibited the highest resistance to Ampicillin (87.2%), while in first-generation cephalosporins: cefalotin 66.7%, third generation: cefotaxime 66.7%, ceftazidime 64.1%, and ceftriaxone 66.7%. Conclusions The ESKAPEE complex species isolated in the hospital displayed diverse resistance profiles against various antibiotic families. Key messages • Monitoring ESKAPEE bacteria’s resistance profiles enables physicians to select appropriate antibiotics at optimal dosages and timings. • Physician should know the rate of resistance of the antibiotics that they use for treatment of ESKAPEE bacteria.

Antimicrobial stewardship program in one primary care hospital, a snapshot analysis

Abstract Antimicrobic resistance (AMR) continues to rise, whereas development of new agents to counter it has slowed. A heightened need to maintain the effectiveness of currently available agents exists. Healthcare-associated infections (HAIs) are a significant cause of poor treatment outcomes and elevated healthcare and societal costs worldwide. At the beginning of 2024, we started a prospective, interventional, interrupted time-series study, based on Prospective Audit and Feedback in the Intensive Care Unit (ICU) and in the internal medicine ward of our hospital. The primary outcomes will be the difference in the antibiotic consumption, and the incidence of bloodstream infections (BSI) caused by multidrug-resistant (MDR) organisms. The secondary outcomes will include the hospital mortality rate, the mean length of stay and the antibiotic expense. We conducted a snapshot analysis of the first three months to assess the efficacy our program. In the first three months we registered a global reduction in antibiotic expense (almost by half in comparison of 2023 first quarter) and consumption, particularly in the use of carbapenems: (change in level, CL: -51,26 DDD/1000 PD,) and third- generation cephalosporins (CL: -6 DDD/1000 PD). We registered a reduction in the use of hydroalcoholic gel, probably due to the reducted perception after the waning of risk perception towards Covid-19, although no big difference was observed in BSI incidence due to MDR Gram-negative organisms (CL: +1,2 events/1000 PD). Albeit partial, once again these findings demonstrated that implementation of an antimicrobial stewardship program, no matter the level of healthcare, is critical for fighting the AMR and to lessen the burden on Public Health; in particular our program induced a significant reduction in antibiotic consumption that lead to more funds at disposal to improve our clinical practice. Key messages • Once again our findings demonstrated that implementation of an antimicrobial stewardship, no matter the level of healthcare, is critical for fighting the AMR. • Our program induced a significant reduction in antibiotic consumption.

The Challenge of Treating Infections Caused by Metallo-β-Lactamase-Producing Gram-Negative Bacteria: A Narrative Review.

Gram-negative multidrug-resistant (MDR) bacteria, including Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa, pose a significant challenge in clinical practice. Infections caused by metallo-β-lactamase (MBL)-producing Gram-negative organisms, in particular, require careful consideration due to their complexity and varied prevalence, given that the microbiological diagnosis of these pathogens is intricate and compounded by challenges in assessing the efficacy of anti-MBL antimicrobials. We discuss both established and new approaches in the treatment of MBL-producing Gram-negative infections, focusing on 3 strategies: colistin; the recently approved combination of aztreonam with avibactam (or with ceftazidime/avibactam); and cefiderocol. Despite its significant activity against various Gram-negative pathogens, the efficacy of colistin is limited by resistance mechanisms, while nephrotoxicity and acute renal injury call for careful dosing and monitoring in clinical practice. Aztreonam combined with avibactam (or with avibactam/ceftazidime if aztreonam plus avibactam is not available) exhibits potent activity against MBL-producing Gram-negative pathogens. Cefiderocol in monotherapy is effective against a wide range of multidrug-resistant organisms, including MBL producers, and favorable clinical outcomes have been observed in various clinical trials and case series. After examining scientific evidence in the management of infections caused by MBL-producing Gram-negative bacteria, we have developed a comprehensive clinical algorithm to guide therapeutic decision making. We recommend reserving colistin as a last-resort option for MDR Gram-negative infections. Cefiderocol and aztreonam/avibactam represent favorable options against MBL-producing pathogens. In the case of P. aeruginosa with MBL-producing enzymes and with difficult-to-treat resistance, cefiderocol is the preferred option. Further research is needed to optimize treatment strategies and minimize resistance.

Epidemiology of Bacteremia in Patients with Hematological Malignancies and Hematopoietic Stem Cell Transplantation and the Impact of Antibiotic Resistance on Mortality: Data from a Multicenter Study in Argentina

The epidemiology of bacteremia and the antibiotic resistance profile (ARP) of Gram-negative bacilli (GNB) in hematological malignancies (HM) and hematopoietic stem cell transplant (HSCT) patients may differ according to geographic region. In addition, multidrug-resistant organisms (MDROs) may impact mortality. This is a prospective, observational, and multicenter study. The first episodes of bacteremia in adult patients with HM or HSCT were included. The risk factors for 30-day mortality were identified. One thousand two hundred and seventy-seven episodes were included (HM: 920; HSCT: 357). GNB were isolated in 60.3% of episodes, with Enterobacterales (46.9%) and P. aeruginosa (8.5%) being the most frequent. Gram-positive cocci were isolated in 41.9% of episodes, with coagulase-negative staphylococci (19.8%) and S. aureus (10.4%) being the most frequent. MDROs were isolated in 40.2% (24.4% GNB). The ARP of GNB in patients with HM vs. HSCT was cefepime: 36.8% vs. 45.7% (p = 0.026); piperacillin–tazobactam: 31.05% vs. 45.2% (p < 0.0001); carbapenems: 18.9% vs. 27.3% (p = 0.012); and aminoglycosides: 9.3% vs. 15.4% (p = 0.017), respectively. Overall mortality between patients with HM and HSCT was 17.5% vs. 17.6% (p = 0.951), respectively. The risk factors for mortality were relapsed and refractory underlying disease, corticosteroids use, respiratory source, septic shock, and GNB resistant to meropenem, while 7-day clinical response was a protective factor for survival. Bacteremia was frequently caused by GNB, with a large proportion of MDROs and a high level of antibiotic resistance, especially in patients with HSCT. Carbapenem-resistant GNB bacteremia was associated with a significant increase in mortality.

Antimicrobial resistance in Enterobacterales, Acinetobacter spp. and Pseudomonas aeruginosa isolates from bloodstream infections in Australian children, 2013-2021.

Gram-negative bloodstream infections are associated with significant morbidity and mortality in children. Increasing antimicrobial resistance (AMR) is reported globally, yet efforts to track pediatric AMR at a national level over time are lacking. The Australian Group on Antimicrobial Resistance (AGAR) surveillance program captures clinical and microbiological data of isolates detected in blood cultures across Australia. EUCAST 2022 was used for MIC interpretation and the AMR package in R for data analysis. Over a nine-year period, there were 3,145 bloodstream infections with 3,266 gram-negative isolates reported in hospitalized children aged <18 years; 21.0% were from neonates. The median length of stay was 9 days, and 30-day all-cause mortality was 5.2%. A greater odds of death was observed in those with a multi-drug resistant organism (aOR: 2.1, 95%CI: 1.3, 3.3, p: 0.001). Escherichia coli (44.5%) and Klebsiella pneumoniae complex (12.6%) were the two most frequently reported organisms. Overall resistance in Enterobacterales to gentamicin/tobramycin was 11.6%, to ceftazidime/ceftriaxone was 12.9%, and 13.2% to ciprofloxacin. Resistance increased over time.Of 201 Pseudomonas aeruginosa isolates reported, 19.7% were resistant to piperacillin-tazobactam, 13.1% resistant to cefepime/ceftazidime and 9.8% to ciprofloxacin. Of 108 Acinetobacter spp. isolates, one was resistant to meropenem, and two were resistant to ciprofloxacin. Resistance did not increase over time. AMR in gram-negative organisms causing bloodstream infections in Australian children is increasing which should be considered when updating guidelines and empiric treatment regimens. Ongoing pediatric-specific national surveillance with pediatric reporting must remain a priority to strengthen antimicrobial stewardship and infection control programs.

Therapy of Aspiration: Out-of-Hospital and In-Hospital-Acquired.

Therapeutic considerations for aspiration pneumonia prioritize the risk of multidrug-resistant organisms. This involves integrating microbiological insights with each patient's unique risk profile, including the location at the time of aspiration, and whether it occurred in or out of the hospital. Our understanding of the microbiology of aspiration pneumonia has also evolved, leading to a reassessment of anaerobic bacteria as the primary pathogens. Emerging research shows a predominance of aerobic pathogens, in both community and hospital-acquired cases. This shift challenges the routine use of broad-spectrum antibiotics targeting anaerobes, which can contribute to antibiotic resistance and complications such as Clostridium difficile infections-concerns that are especially relevant given the growing issue of antimicrobial resistance. Adopting a comprehensive, patient-specific approach that incorporates these insights can optimize antibiotic selection, improve treatment outcomes, and reduce the risk of resistance and adverse effects.

A Retrospective Closed Cohort Study on Distribution of Multidrug-Resistant Bacteria in Ventilator-Associated Pneumonia and its Impact on Patient Outcome.

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection affecting critically ill patients undergoing mechanical ventilation. This study investigated the prevalence of multidrug-resistant (MDR) organisms in VAP, the VAP rate, and the outcomes associated with MDR-VAP. This retrospective single-center study, conducted in 2022, included adult ICU cases from April 2021 to March 2022, receiving mechanical ventilation for more than 48 h. Patient data were analyzed for demographics, comorbidities, empirical antibiotic use, and outcomes. MDR organisms were identified in respiratory cultures. Among 447 patients, 133 developed VAP, with 96 cases being MDR-VAP. The mean age of the overall VAP population was 52 years, 70% of which were males. The incidence of VAP was 30.0% (95% CI: 25.7%-34.5%), while that of MDR-VAP was 21.6% (95% CI: 17.9%-25.8%). The most prevalent MDR organisms were Acinetobacter species (50%) and Klebsiella pneumoniae (46.9%). Empirical antibiotics were administered in 96% of VAP cases. The overall VAP rate was 38.03/1000 ventilator days. No single antimicrobial agent seemed to offer an empirical cover, as the susceptibility rate for most tested antimicrobials was less than 85%. Patients with MDR-VAP had a low survival rate (64.6%) and were less likely to be extubated at 13.5% compared to non-MDR-VAP (survival rate of 62.2%). COVID-19 patients had a high incidence of MDR VAP, especially with Acinetobacter. Overall, VAP mortality was 57.1%. The median ventilator days were 16 for VAP and only four for non-VAP. Gram-negative organisms, particularly Klebsiella and Acinetobacter, were the main MDR VAP culprits. MDR-VAP exhibited higher morbidity and mortality. A study focused on developing resistance by microorganisms is warranted for further understanding.

Emergence of resistance to last-resort antimicrobials in bacteremia patients: A multicenter analysis of bloodstream pathogens in Korea.

This study retrospectively reviewed the microbiological and clinical characteristics of patients diagnosed with bacteremia. Results from the first positive blood cultures were consecutively collected from July 2022 to June 2023 at a public secondary hospital, a university-affiliated tertiary hospital, and a university-affiliated secondary hospital in the Seoul metropolitan area. Antibiotic spectrum coverage (ASC) scores were calculated on the day the blood culture was performed (B0) and on two days after the blood culture results were reported (R+2). A total of 3,397 isolates were collected from 3,094 patients. Among these, 949 isolates obtained from 893 patients were classified as multidrug-resistant organisms (MDRO), including 170 imipenem-resistant gram-negative bacteria, 714 methicillin-resistant staphylococci, and 65 vancomycin-resistant enterococci. Interestingly, 13 and 42 gram-positive isolates were resistant to linezolid and quinupristin/dalfopristin, respectively. Moreover, 44 and 181 gram-negative isolates were resistant to amikacin and tigecycline, respectively. The proportion of ASC scores corresponding to broad or extremely broad-spectrum coverage was not significantly different between MDRO and non-MDRO groups at B0 (p = 0.0925). However, it increased in the MDRO group at R+2 (p <0.001). This study found that resistance to last-resort antimicrobials is emerging. Therefore, developing and incorporating molecular diagnostics using a wide range of resistance targets may facilitate rapid, tailored antimicrobial treatments.

EFFECT of daily antiseptic bathing with octenidine on ICU-acquired bacteremia and ICU-acquired multidrug-resistant organisms: a multicenter, cluster-randomized, double-blind, placebo-controlled, cross-over study.

Antiseptic bathing has garnered attention in an effort to reduce hospital-acquired infections. Previous studies have shown the efficacy of antiseptic bathing in high-risk environments, such as intensive care units (ICUs), using chlorhexidine. In this study we aimed to evaluate the effectiveness of octenidine as a potential alternative due to its established popularity and widespread use in Europe. We compared the rates of ICU-acquired primary bacteremia and ICU-acquired multidrug-resistant organisms (MDROs) in a multicenter, cluster-randomized, double-blind, placebo-controlled, cross-over study using octenidine-impregnated and placebo washcloths. On 44 ICUs in 23 hospitals throughout Germany, we compared individual ICUs with themselves over two 12-month time periods. All data were obtained digitally via hospital information systems as individual ward-movement data and microbiological test results; both endpoints were algorithmically derived. 104,039 ICU episodes from 93,438 patients with 712,784 microbiological test results were analyzed, thereby detecting 1508 cases of ICU-acquired primary bacteremia and 1871 cases of ICU-acquired MDRO. Bathing with octenidine-impregnated washcloths prevented ICU-acquired primary bacteremia; a risk reduction of 17% was seen homogeneously across all participating ICUs (adjusted hazard ratio (HR) 0.83, 95% confidence interval (CI) [0.75; 0.92], p = 0.0003). This reduction affected predominantly coagulase-negative staphylococci (53%) and enterococci (17%). However, no intervention effect was seen for ICU-acquired MDROs (adjusted HR 0.98, 95% CI [0.83; 1.15]). Heterogeneity among intra-ICU intervention effects on MDRO acquisition was substantial. Antiseptic bathing with octenidine may be effective in preventing ICU-acquired primary bacteremia, particularly due to Gram-positive bacteria and common skin commensals.

Corynebacterium striatum

Abstract Corynebacterium striatum (C. striatum) is a rapidly emerging multidrug-resistant organism commonly found as a skin and respiratory tract commensal. The first case of C. striatum infection was published in 1980 in a patient with chronic lymphocytic leukemia who had a pleuropulmonary infection. The chemotherapeutic agents used in hematologic malignancies completely deplete neutrophils, making them susceptible to various pathogens such as C. striatum, which are rarely pathogenic. The spectrum of presentation due to C. striatum includes severe bloodstream infections, pneumonia, meningitis, and infective endocarditis. Some of the most common risk factors are prolonged neutropenia with various invasive devices and numerous prophylactic antibiotics. This article aims to present three cases of C. striatum infections in immunocompromised patients at H. Lee Moffitt Cancer Centre. In such rare cases, infection prevention and appropriate antibiotic coverage are the key to preventing such infections.

Risk of invasive MDRO infection in MDRO-colonized patients.

In this study, we aim to estimate the risk of developing clinical multidrug-resistant organism (MDRO) infection with carbapenem-resistant Enterobacterales (CRE), methicillin-resistant Staphylococcus aureus (MRSA), or vancomycin-resistant enterococci (VRE) in colonized patients compared with non-colonized admitted to high-risk areas with a main focus on CRE colonization/infection. Retrospective cohort study conducted at a tertiary care facility. This study included patients enrolled in active surveillance testing (AST) for CRE, MRSA, or VRE during the year 2021. Development of relevant invasive infection within 365 days of the AST result was collected as the primary outcome. The association between MDRO colonization and infection was calculated using the risk ratio. The prevalence of CRE organisms and carbapenemase genes is presented. A total of 19,134 ASTs were included in the analysis (4,919 CRE AST, 8,303 MRSA AST, and 5,912 VRE AST). Patient demographics were similar between colonized and non-colonized groups. Colonization was associated with an increased risk of infection in the 3 cohorts (CRE, MRSA, and VRE), with risk ratios reported as 4.6, 8.2, and 22, respectively. Most patients (88%) develop CRE infection with the same colonizing carbapenemase gene. Oxa-48/NDM Klebsiella pneumoniae was the most common organism detected in CRE infection. The study demonstrated that colonization with CRE, MRSA, or VRE is a risk factor for developing infections caused by the respective bacteria. The high percentage of match between carbapenemase genes detected in colonization and infection indicates that screening results might be used to inform infection management and treatment.

Surgical Site Infections: Risk Factors for Multiple Antibiotic Resistance in Abdominal Surgery

INTRODUCTION. Multidrug-resistant (MDR) organisms are increasingly becoming a major surgical site infection (SSI); however, the clinical outcomes and risk factors associated with resistant pathogens in general surgery remain poorly understood.THE AIM of the present research is to study the risk factors and consequences of infections in patients with SSI caused by antibiotic resistant pathogens with MDR.MATERIAL AND METHODS. A single-center, retrospective case-control study was carried out. The results of the examination and treatment of 50 patients with SSI + MDR, who made up the main group, and two control groups — non-MDR SSI and no SSI, 50 patients each, were analyzed. A total of 38 risk factors were used: pre- and surgical criteria, clinical, biochemical, instrumental data, postoperative complications and treatment features. The microbial landscape was studied in SSI+MDR. Single- and multivariate analysis was carried out, binary and multinomial logistic regression was performed. P-values &lt;0.05 were considered significant at 95% CI.RESULTS. Significant risk factors were as follows: previous hospitalization, previous antibiotic therapy, terms of preoperative stay of the patient in the department, emergency surgery, class of surgery, decrease in the ratio of ALP/ ALPI, MEI and EMFC (p&lt;0.01); elevated ASA score, obesity, low levels of plasma proteins and albumin, (p&lt;0.05). Among the pathogens, there were more gram-negative enterobacteria (61%) than gram-positive ones (30.5%). Escherichia coli (36.3%) was the most commonly found bacterium, followed by Enterococcus faecium (9.09%), Morganella morganii (7.58%), Staphylococcus aureus (6%), and Pseudomonas aeruginosa (6%). In SSSI, Staphylococcus spp. prevailed. (&gt;80%); in DSSI — Echerichia, Acinetobacter (&gt;70%); and in OSSSI — Enterobacter spp., Acinetobacter and Citrobacter (&gt;90%). SSI+MDR were characterized by serious surgical complications (Clavien Dindo Classification grade 3–5), wound dehiscences and OSSSI, reoperations (p&lt;0.05).CONCLUSION. 1. The primary risk factors for multiple antibiotic resistance were as follows: previous hospitalization, previous antibiotic therapy, the duration of the patient’s preoperative stay in the department, emergency surgery, surgery class, reduced ALP/ALPI ratio, MEI and EMFC. In addition to the above, the following were also of great importance: increased ASA score, obesity, low plasma proteins, albumin.2. When identifying risk factors for multiple antibiotic resistance in surgical patients, the development of severe postoperative complications, sepsis and multiple organ failure can be predicted.3. Perioperative medical and preventive measures require a multidisciplinary approach involving the microbiologist, pharmacologist, immunologist, nutrition specialist, and other expert consultants.

High Mortality Rates and Antimicrobial Resistance in Children with Invasive Bacterial Infections in a Tertiary Care Facility in West Africa

Abstract Background Childhood data on infection mortality and antimicrobial resistance in Sub-Saharan Africa are emerging but remain limited. The University of Maryland Center for Vaccine Development (CVD) and CVD-Mali have been conducting a prospective observational study at L’Hopital Gabriel Toure (HGT), a referral hospital in Bamako, Mali, since 2002 to identify causes of invasive bacterial infections (IBI) in children. These data have been used to initiate vaccination programs to decrease the burden of Haemophilus influenzae type b and Streptococcus pneumoniae. Additional demographic and antimicrobial susceptibility data have been collected since 2021, allowing for more detailed resistance and mortality analyses. Methods All children presenting to HGT are screened. Children ages 0-15 years with temperature of at least 39 degrees Celsius and/or suspicion of IBI are eligible. Eligible children have blood cultures collected with additional site-specific cultures when focal infection is suspected. Cultures are performed using the Bactec system; when positive, Gram staining, sub-culturing, and antimicrobial susceptibility testing (by disk diffusion using standard methods) are performed. Organisms thought to be contaminants are excluded. American type culture collection strains are utilized for quality control. Results Between 1/14/2021 and 9/14/2023, 28703 patients were screened. 2156 patients were included. 212 patients (10%) had 235 pathogens isolated. Gram positive organisms were most frequently isolated (N=112), followed by Gram negative Enterobacterales (N=81), non-Enterobacterales Gram negatives (N=36), and yeast (N=6). Staphylococcus aureus was the most frequently isolated Gram positive organism (59 bloodstream isolates, 2 joint isolates, 2 subcutaneous isolates) followed by S.pneumoniae (10 bloodstream isolates, 17 cerebrospinal fluid isolates, 1 joint isolate) and Enterococcus species (16 bloodstream isolates). Klebsiella pneumoniae (28 bloodstream isolates, 2 cerebrospinal fluid isolates) and Escherichia coli (18 bloodstream isolates, 3 cerebrospinal fluid isolates, 2 subcutaneous isolates) were the most frequently isolated Gram negative Enterobacterales, with Pseudomonas species most common among non-Enterobacterales Gram negative organisms (16 bloodstream isolates, 1 cerebrospinal fluid isolate). Mortality rates in both culture-positive and culture-negative patients were high (52% and 28%, respectively), with greater than 50% of deaths occurring within 48 hours in both groups. 88% of Gram negative Enterobacterales were ceftriaxone resistant or intermediate, with 56% ciprofloxacin resistant or intermediate; 55% of isolates were resistant or intermediate to both. 71% of isolates were gentamicin resistant. Imipenem resistance remained low, with 91% of isolates retaining sensitivity. 24% of S. aureus isolates were oxacillin resistant and 34% of isolates were resistant or intermediate to trimethoprim/sulfamethoxazole. 100% of S. aureus isolates tested (14/60) retained sensitivity to clindamycin. Only 54% of pneumococcal isolates had positive oxacillin screens, implying frequent penicillin resistance, and only 60% of enterococcal species were ampicillin sensitive, although 92% retained vancomycin sensitivity. Conclusion We found higher mortality rates in our study than in similar studies; the contribution of issues such as limited access to advanced supportive care and delay in presentation is an area for further study. The high frequency of multidrug-resistant organisms is alarming, suggesting an urgent need to investigate underlying contributing factors, increase access to affordable broad-spectrum antibiotics, and create robust antimicrobial stewardship programs.

Comparative Properties of Helical and Linear Amphipathicity of Peptides Composed of Arginine, Tryptophan, and Valine.

The persistence of antibiotic resistance has incited a strong interest in the discovery of agents with novel antimicrobial mechanisms. The direct killing of multidrug-resistant bacteria by cationic antimicrobial peptides (AMPs) underscores their importance in the fight against infections associated with antibiotic resistance. Despite a vast body of AMP literature demonstrating a plurality in structural classes, AMP engineering has been largely skewed toward peptides with idealized amphipathic helices (H-amphipathic). In contrast to helical amphipathicity, we designed a series of peptides that display the amphipathic motifs in the primary structure. We previously developed a rational framework for designing AMP libraries of H-amphipathic peptides consisting of Arg, Trp, and Val (H-RWV, with a confirmed helicity up to 88% in the presence of membrane lipids) tested against the most common MDR organisms. In this study, we re-engineered one of the series of the H-RWV peptides (8, 10, 12, 14, and 16 residues in length) to display the amphipathicity in the primary structure by side-by-side (linear) alignment of the cationic and hydrophobic residues into the 2 separate linear amphipathic (L-amphipathic) motifs. We compared the 2 series of peptides for antibacterial activity, red blood cell (RBC) lysis, killing and membrane-perturbation properties. The L-RWV peptides achieved the highest antibacterial activity at a minimum length of 12 residues (L-RWV12, minimum optimal length or MOL) with the lowest mean MIC of 3-4 µM, whereas the MOL for the H-RWV series was reached at 16 residues (H-RWV16). Overall, H-RWV16 displayed the lowest mean MIC at 2 µM but higher levels of RBC lysis (25-30%), while the L-RWV series displayed minor RBC lytic effects at the test concentrations. Interestingly, when the S. aureus strain SA719 was chosen because of its susceptibility to most of the peptides, none of the L-RWV peptides demonstrated a high level of membrane perturbation determined by propidium iodide incorporation measured by flow cytometry, with <50% PI incorporation for the L-RWV peptides. By contrast, most H-RWV peptides displayed almost up to 100% PI incorporation. The results suggest that membrane perturbation is not the primary killing mechanism of the L-amphipathic RWV peptides, in contrast to the H-RWV peptides. Taken together, the data indicate that both types of amphipathicity may provide different ideal pharmacological properties that deserve further investigation.