Multidrug-resistant Organism Infection Research Articles

Stewardship Prompts to Improve Antibiotic Selection for Pneumonia

Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. ClinicalTrials.gov Identifier: NCT03697070.

Impact of Multidrug-Resistant Organisms on Severe Acquired Brain Injury Rehabilitation: An Observational Study.

Healthcare-associated infections (HAIa) and antimicrobial resistance are expected to be the next threat to human health and are most frequent in people with severe acquired brain injury (SABI), who can be more easily colonized by multidrug-resistant organisms (MDROs). The study's aim is to investigate the impact of MDRO colonizations and infections on SABI rehabilitation outcomes. This retrospective observational study was performed in a tertiary referral specialized rehabilitation hospital. The main outcomes were the presence of carbapenemase-producing Enterobacteriaceae (CPE) colonization, type and timing of HAI and MDRO HAI, and the number of CPE transmissions. We included 48 patients, 31% carrying CPE on admission and 33% colonized during the hospitalization. A total of 101 HAI were identified in 40 patients, with an overall incidence of 10.5/1000 patient days. Some 37% of patients had at least one MDRO infection, with a MDRO infection incidence of 2.8/1000 patient days. The number of HAIs was significantly correlated with the length of stay (LOS) (r = 0.453, p = 0.001). A significant correlation was found between colonization and type of hospital room (p = 0.013). Complications and HAI significantly affected LOS. We suggest that CPE carriers might be at risk of HAI and worse outcomes compared with non-CPE carriers.

Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection

Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. ClinicalTrials.gov Identifier: NCT03697096.

Nosocomial Infections After Pediatric Congenital Heart Disease Surgery: Data from National Center for Cardiovascular Diseases in China.

Infection prevention and control (IPC) has a significant impact on the prognosis after pediatric cardiac surgery. This study aimed to provide surveillance data on the incidence and density of various infections during the COVID-19 epidemic and explore the influence of multi-drug resistant organisms (MDRO) on in-hospital prognosis after congenital heart disease surgery. This single-center retrospective study included pediatric patients who underwent cardiac surgery between 2021 and 2022. The results of the postoperative bacterial and fungal cultures and antimicrobial stewardship were collected. The demographic characteristics (age and weight), operation-related parameters (RACHS-1 grade, duration of cardiopulmonary bypass, and aortic cross clamp), and surgical outcomes (extracorporeal membrane oxygenation, delayed sternal closure, mortality, duration of mechanical ventilation, length of intensive care unit stay and hospital stay, and hospitalization costs) of MDRO and non-MDRO patients were compared. A total of 4776 patients were included. There were 101 infectious culture results after the operation, with a nosocomial infection rate of 2.1%. There were 40 MDRO specimens from 36 patients, 50 non-MDRO specimens from 30 patients, and 11 fungal specimens from 10 patients. The incidence of pneumonia was 1.5%, with a ventilator-associated pneumonia incidence density of 7.2/1000 patient-days. The incidence of sepsis was 0.4%, with a catheter-related bloodstream infection incidence density of 0.24/ 1000 patient-days. The incidence density of catheter-associated tract infection was 0.45/ 1000 patient-days. The incidence of surgical site infection was 0.06%. The culture proportion before commencing antibiotics was 93% and the antibiotic consumption intensity was 30.7 DDD/100 bed-days. The length of intensive care unit stay in MDRO infection patients increased compared with that in non-MDRO infection patients, 30 (18,52) vs 17 (7,62) days, p=0.05). The IPC performance of Fuwai Hospital achieved satisfactory results. MDRO infection can lead to prolonged intensive care unit stay.

Reducing Hospitalizations and Multidrug-Resistant Organisms via Regional Decolonization in Hospitals and Nursing Homes

Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalization, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. To evaluate whether implementation of a decolonization collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalizations, costs, and deaths. This quality improvement study was conducted from July 1, 2017, to July 31, 2019, across 35 health care facilities in Orange County, California. Chlorhexidine bathing and nasal iodophor antisepsis for residents in long-term care and hospitalized patients in contact precautions (CP). Baseline and end of intervention MDRO point prevalence among participating facilities; incident MDRO (nonscreening) clinical cultures among participating and nonparticipating facilities; and infection-related hospitalizations and associated costs and deaths among residents in participating and nonparticipating nursing homes (NHs). Thirty-five facilities (16 hospitals, 16 NHs, 3 long-term acute care hospitals [LTACHs]) adopted the intervention. Comparing decolonization with baseline periods among participating facilities, the mean (SD) MDRO prevalence decreased from 63.9% (12.2%) to 49.9% (11.3%) among NHs, from 80.0% (7.2%) to 53.3% (13.3%) among LTACHs (odds ratio [OR] for NHs and LTACHs, 0.48; 95% CI, 0.40-0.57), and from 64.1% (8.5%) to 55.4% (13.8%) (OR, 0.75; 95% CI, 0.60-0.93) among hospitalized patients in CP. When comparing decolonization with baseline among NHs, the mean (SD) monthly incident MDRO clinical cultures changed from 2.7 (1.9) to 1.7 (1.1) among participating NHs, from 1.7 (1.4) to 1.5 (1.1) among nonparticipating NHs (group × period interaction reduction, 30.4%; 95% CI, 16.4%-42.1%), from 25.5 (18.6) to 25.0 (15.9) among participating hospitals, from 12.5 (10.1) to 14.3 (10.2) among nonparticipating hospitals (group × period interaction reduction, 12.9%; 95% CI, 3.3%-21.5%), and from 14.8 (8.6) to 8.2 (6.1) among LTACHs (all facilities participating; 22.5% reduction; 95% CI, 4.4%-37.1%). For NHs, the rate of infection-related hospitalizations per 1000 resident-days changed from 2.31 during baseline to 1.94 during intervention among participating NHs, and from 1.90 to 2.03 among nonparticipating NHs (group × period interaction reduction, 26.7%; 95% CI, 19.0%-34.5%). Associated hospitalization costs per 1000 resident-days changed from $64 651 to $55 149 among participating NHs and from $55 151 to $59 327 among nonparticipating NHs (group × period interaction reduction, 26.8%; 95% CI, 26.7%-26.9%). Associated hospitalization deaths per 1000 resident-days changed from 0.29 to 0.25 among participating NHs and from 0.23 to 0.24 among nonparticipating NHs (group × period interaction reduction, 23.7%; 95% CI, 4.5%-43.0%). A regional collaborative involving universal decolonization in long-term care facilities and targeted decolonization among hospital patients in CP was associated with lower MDRO carriage, infections, hospitalizations, costs, and deaths.

Stethoscope barriers narrative review; It's time for a strategy unfriendly to multi-drug resistant organisms (MDROs)

The current standard of stethoscope hygiene doesn’t eliminate the transmission of harmful pathogens, including multi-drug resistant organisms (MDROs). In the era of the increasing prevalence of MDRO infections, the use of new systems providing touch free barriers may improve patient safety versus traditional stethoscope cleaning practices with chemical agents. Our purpose was to provide a narrative literature review regarding barriers as an improvement over the current standard of care for stethoscope hygiene. Searching PubMed, articles were identified if they were in English and published after 1990, using the search term “stethoscope barrier”, or if they were from a previously published stethoscope hygiene article using “author’s name + stethoscope”. Included articles evaluated or discussed stethoscope barriers. Of 28 manuscripts identified, 15 met the inclusion criteria. Barriers were considered superior to alternatives if they were single use, disposable, applied in a touch free fashion, were impervious to pathogens, provided an aseptic patient contact, and were acoustically invisible. Use of a practitioner’s personal stethoscope with a disposable diaphragm barrier should be recommended as a new standard of care as this represents an improvement in patient safety and patient experience when compared to the disposable stethoscope or isopropyl alcohol stethoscope diaphragm cleaning.

Terlipressin therapy is associated with increased risk of colonisation with multidrug-resistant bacteria in patients with decompensated cirrhosis.

Patients with cirrhosis are susceptible to develop bacterial infections that trigger acute decompensation (AD) and acute-on-chronic liver failure (ACLF). Infections with multidrug-resistant organisms (MDRO) are associated with deleterious outcome. MDRO colonisation frequently proceeds MDRO infections and antibiotic therapy has been associated with MDRO colonisation. The aim of the study was to assess the influence of non-antibiotic medication contributing to MDRO colonisation. Three hundred twenty-four patients with AD and ACLF admitted to the ICU of Frankfurt University Hospital with MDRO screening were included. Regression models were performed to identify drugs associated with MDRO colonisation. Another cohort (n = 129) from Barcelona was included to validate. A third multi-centre cohort (n = 203) with metagenomic sequencing data of stool was included to detect antibiotic resistance genes. A total of 97 patients (30%) were identified to have MDRO colonisation and 35 of them (11%) developed MDRO infection. Patients with MDRO colonisation had significantly higher risk of MDRO infection than those without (p = 0.0098). Apart from antibiotic therapy (odds ratio (OR) 2.91, 95%-confidence interval (CI) 1.82-4.93, p < 0.0001), terlipressin therapy in the previous 14 days was the only independent covariate associated with MDRO colonisation in both cohorts, the overall (OR 9.47, 95%-CI 2.96-30.23, p < 0.0001) and after propensity score matching (OR 5.30, 95%-CI 1.22-23.03, p = 0.011). In the second cohort, prior terlipressin therapywas a risk factor for MDRO colonisation (OR 2.49, 95% CI 0.911-6.823, p = 0.075) and associated with risk of MDRO infection during follow-up (p = 0.017). The validation cohort demonstrated that antibiotic inactivation genes were significantly associated with terlipressin administration (p = 0.001). Our study reports an increased risk of MDRO colonisation in patients with AD or ACLF, who recently received terlipressin therapy, while other commonly prescribed non-antibiotic co-medications had negligible influence. Future prospective trials are needed to confirm these results.

The Burden and Impact of Early Post-transplant Multidrug-Resistant Organism Detection Among Renal Transplant Recipients, 2005-2021.

Reducing the burden of multidrug-resistant organism (MDRO) colonization and infection among renal transplant recipients (RTRs) may improve patient outcomes. We aimed to assess whether the detection of an MDRO or a comparable antibiotic-susceptible organism (CSO) during the early post-transplant (EPT) period was associated with graft loss and mortality among RTRs. We conducted a retrospective cohort study of RTRs transplanted between 2005 and 2021. EPT positivity was defined as a positive bacterial culture within 30 days of transplant. The incidence and prevalence of EPT MDRO detection were calculated. The primary outcome was a composite of 1-year allograft loss or mortality following transplant. Multivariable Cox hazard regression, competing risk, propensity score-weighted sensitivity, and subgroup analyses were performed. Among 3507 RTRs, the prevalence of EPT MDRO detection was 1.3% (95% CI, 0.91%-1.69%) with an incidence rate per 1000 EPT-days at risk of 0.42 (95% CI, 0.31-0.57). Among RTRs who met survival analysis inclusion criteria (n = 3432), 91% (3138/3432) had no positive EPT cultures and were designated as negative controls, 8% (263/3432) had a CSO detected, and 1% (31/3432) had an MDRO detected in the EPT period. EPT MDRO detection was associated with the composite outcome (adjusted hazard ratio [aHR], 3.29; 95% CI, 1.21-8.92) and death-censored allograft loss (cause-specific aHR, 7.15; 95% CI, 0.92-55.5; subdistribution aHR, 7.15; 95% CI, 0.95-53.7). A similar trend was seen in the subgroup and sensitivity analyses. MDRO detection during the EPT period was associated with allograft loss, suggesting the need for increased strategies to optimize prevention of MDRO colonization and infection.

Exploring the Prevalence, Predictors, and Impact of Bacterial Infections to Guide Empiric Antimicrobial Decisions in Cirrhosis (EPIC-AD)

BackgroundThis study delved into cirrhosis-related infections to unveil their epidemiology, risk factors, and implications for antimicrobial decisions. MethodsWe analyzed acutely decompensated cirrhosis patients (n=971) from North India between 2013-2023 at a tertiary center. Microbiological and clinical features based on infection sites (EASL criteria) and patient outcomes were assessed. ResultsMedian age was 45 years; 87% were males with 47% having alcoholic hepatitis. Of these, 675 (69.5%) had infections; 305 (45%) were culture-confirmed. Notably, 71% of confirmed cases were MDRO-related, chiefly carbapenem-resistant (48%). MDRO prevalence was highest in pulmonary (80.5%) and skin-soft-tissue infections (76.5%). Site-specific distribution and antimicrobials were suggested.Predictive models identified prior hospitalization [OR:2.23 (CI:1.58-3.14)], norfloxacin prophylaxis [OR:2.26 (CI:1.44-3.55)], prior broad-spectrum antibiotic exposure [OR:1.61 (CI:1.12-2.30)], presence of SIRS [OR:1.75 (CI: 1.23-2.47)], procalcitonin [OR:4.64 (CI:3.36-6.40)], and HE grade [OR:1.41 (CI:1.04-1.90)], with an AUC of 0.891 for infection prediction. For MDRO infection prediction, second infection [OR: 7.19 (CI: 4.11-12.56)], norfloxacin prophylaxis [OR: 2.76 (CI: 1.84-4.13)], CLIF-C OF [OR: 1.10 (CI: 1.01-1.20)], prior broad-spectrum antibiotic exposure [OR: 1.66 (CI: 1.07-2.55)], rifaximin [OR: 040 (0.22-0.74)] multisite [OR: 3.67 (CI: 1.07-12.56)], and polymicrobial infection [OR: 4.55 (CI: 1.45-14.17)] yielded an AUC of 0.779 and 93% specificity. Norfloxacin prophylaxis, multisite infection, mechanical ventilation, prior broad-spectrum antibiotic exposure, and infection as acute precipitant predicted carbapenem-resistant infection (AUC: 0.821).Infections (culture-proven or probable), MDROs, carbapenem/pan-drug resistance, and second infections independently linked with mortality (p<0.001), adjusted for age, leucocytosis, and organ failures. A model incorporating age [HR:1.02 (CI: 1.01-1.03), infection [HR:1.52 (CI: 1.05-2.20)], prior hospitalization [HR:5.33 (CI: 3.75-7.57)], norfloxacin [HR:1.29 (CI: 1.01-1.65)], multisite infection [HR:1.47 (CI:1.06-2.04)], and CLIF-C OF [HR:1.17 (CI: 1.11-1.23)] predicted mortality with C-statistics of 0.782 (p<0.05). ConclusionHigh MDRO burden, especially carbapenem-resistant, necessitates urgent control measures in cirrhosis. Site-specific epidemiology and risk models can guide empirical antimicrobial choices in cirrhosis management. Lay summaryOur study delved into infections among hospitalized cirrhosis patients, investigating their occurrence, distribution, risks, and consequences. Notably, infections affected almost 70% of patients, with nearly half of them being confirmed through culture. Most concerning was the identification of multidrug-resistant organisms (MDROs) in 71% of culture-proven cases, particularly carbapenem-resistant bacteria (48%). Pulmonary and skin-soft-tissue infections were the hardest hit. We developed predictive models to foresee infections and particularly drug-resistant and carbapenem-resistant bacterial infections and their mortality. Thus, highlighting the urgent need for measures to counter the substantial impact of MDRO infections in cirrhosis patients. Our findings underscore the importance of targeted antimicrobial therapy guided by site-specific epidemiological insights.

Impact of the COVID-19 pandemic on the incidence and type of infections in hospitalized patients with cirrhosis: a retrospective study

Infections are a major cause of morbidity and mortality in cirrhosis, especially those caused by multi-drug resistant bacteria. During the COVID-19 pandemic, the incidence and type of infection in these patients may have been influenced by the restrictive measures implemented. We aimed to compare the infections in patients with cirrhosis hospitalized before the COVID-19 pandemic versus those hospitalized during the pandemic. We retrospectively compared infections in patients with cirrhosis hospitalized in the hepatology unit during the pre-pandemic period (3/2019–2/2020) with infections in patients hospitalized during the pandemic (3/2020–2/2021). Baseline characteristics, type of infections, type of bacteria, antimicrobial resistance and mortality were evaluated. There were 251 hospitalizations in 170 patients during the pre-pandemic period and 169 hospitalizations in 114 patients during the pandemic period. One or more infections were identified in 40.6% of hospitalizations during the pre-pandemic period and 43.8% of hospitalizations during the pandemic, P = 0.52. We found 131 infections in the pre-pandemic period and 75 infections during the pandemic. The percentage of nosocomial infections decreased in the pandemic period (25.3% vs. 37.4% in the pre-pandemic period, P = 0.06). We found a non-significant trend to a higher incidence of infections by multi-drug resistant organisms (MDRO) in the pandemic period than in the pre-pandemic period (6.5% vs. 4%). The incidence of infections was similar in both periods. However, during the pandemic, we observed a trend to a lower incidence of nosocomial infections with a higher incidence of MDRO infections.

Impact of the 4th of August Beirut explosion mass casualty incident on a university hospital microbial Flora

BackgroundFollowing the Beirut explosion, our university hospital received at least 350 casualties. Subsequently, infection control standard practices were compromised. Concerns for Multi-Drug Resistant Organisms (MDROs) infections in injured patients and a resulting hospital outbreak were raised. The objectives of the study were to compare the rate of hospital growing MDROs 6 months before and 6 months after the Beirut explosion, to identify emerging microorganisms and to evaluate the change in surgical infection prevention practices.MethodsThis is a retrospective chart review of patients with hospital acquired infections (HAI) admitted to the hospital before and after the Beirut explosion. The study was conducted between February 4, 2020 and January 4, 2021. Excluded patients were those transferred from other hospitals and those with community acquired infections. The primary outcome was to identify the rate of growing MDROs post explosion. The secondary outcomes were identifying antibiotics used for surgical prophylaxis in patients requiring surgeries and patients diagnosed with a HAI. Therefore, patients were divided in three groups. Control group included patients admitted with explosion-related injuries on that same day. Patients admitted and between February 4 and August 4 and diagnosed with HAI were compared to those admitted post August 4 with explosion-related HAI and to patients diagnosed with non-explosion-related HAI between August 4 and January 4, 2021. An estimated rate of 18-22% MDRO was needed to achieve a statistical significance with 80% power and 0.05 α. Pearson Chi square test was used to analyze the primary outcome.ResultsA total of 82 patients with 150 cultures were included in this study. Data showed an increase in the rate of MDRO after the explosion with 37.1% of the cultures taken before the explosion and 53.1% after the explosion (p = 0.05). When comparing the types of HAI in both groups, culture sites were significantly different between pre- and post-explosion patients (p = 0.013). However, both groups had similar types of microbes (p = 0.996) with an increase in candida related infections.ConclusionThese findings confirmed that the Beirut explosion impact on antimicrobial resistance was similar to combat zone incidence, where an increase in MDROs rate such as Escherichia coli (E.Coli) and Stenotrophomonas maltophilia, in addition to the increase in candida related infections.

Gut microbiome alpha diversity decreases in relation to body weight, antibiotic exposure, and infection with multidrug-resistant organisms

BackgroundThe human gastrointestinal tract is home to a dense and diverse microbiome, predominated by bacteria. Despite conservation of critical functionality across most individuals, the composition of the gut microbiome is highly individualized, leading to differential responses to perturbations such as oral antibiotics or multidrug-resistant organism (MDRO) infection. Herein, patient responses to these perturbations based upon their body weight were evaluated. MethodsFecal samples were collected from 45 patients at the Detroit Medical Center to evaluate the effects of perturbations on patients’ gut microbiome composition. Bacterial profiling was completed using 16S rRNA gene sequencing. ResultsPatients with multiple MDROs, patients weighing greater than 80kg infected with MDRO E. coli, and patients weighing less than 80kg with exposure to vancomycin and carbapenem antibiotics during hospitalization had significantly decreased gut microbiome richness. ConclusionsBoth administration of oral antibiotics and MDRO infections decreased gut microbiome alpha diversity, but the magnitude of these gut microbiome perturbations was body weight dependent.

Multidrug-Resistant Organisms and Their Association with Risk Factors; A Study at the Intensive Care Unit of Tertiary Care Hospital, Peshawar

Objective: To investigate rates of multidrug-resistant organisms (MDRO) infection, their antimicrobial resistance (AMR) patterns, and risk factors for acquisition of such infections at a Tertiary-Care Hospital ICU. Study Design: Cross sectional study. Place and Duration of Study: Adult Intensive Care Unit of Tertiary Care Hospital, Peshawar Pakistan, from Jan to Dec 2022. Methodology: All patients admitted to adult ICU who developed signs/symptoms of infection after 48 hours of admission were investigated. Microbiological diagnosis was done via standard microbiological practices, and if the patient had acquired an MDRO infection, it was included in the study. Results: During the study, 92 patients acquired MDRO infection in total. The most common source was blood (43.5%). The most common organisms isolated were Klebsiella pneumoniae (21.7%), Acinetobacter baumannii (20.7%) and Pseudomonasaeruginosa (17.4%). The highest percentage of resistance among Gram-positive organisms was exhibited to Penicillin and Co-amoxiclav (91%). Gram-negative isolates exhibited high overall resistance to all used antibiotic classes. The least frequency of resistance was recorded for Tigecycline (1%) against Klebsiella pneumoniae and 33% against Escherichia coli, while 32% Acinetobacter baumannii and 25% Pseudomonas aeruginosa were Colistin/Polymyxin resistant; none of the Klebsiella pneumoniae showed Colistin resistance. Conclusion: Antimicrobial resistance in our setup was high among Gram-negative and Gram-positive organisms. The most common risk factor was central line placement among the patients, highlighting the importance of infection control measures and the need to implement infection control bundles to circumvent infections due to invasive devices.

Infection with multi‑drug resistant organisms in patients with limb fractures: Analysis of risk factors and pathogens.

Infection with multi-drug resistant organisms (MDROs) has emerged as a global problem in medical institutions. Overuse of antibiotics is the main cause of drug resistance. Notably, the incidence of infection with MDROs increases in patients with limb fractures who have undergone invasive surgery. The present study aimed to analyze the risk factors for postoperative MDROs infection in a cohort of patients with limb fractures. A retrospective study was performed on the data of patients with fractures between January 2020 and August 2022. Postoperative surgical site infection occurred in 114 patients in total, of which 47 were infected with MDROs. Univariate logistic regression analysis and multivariate binary logistic regression were used to confirm the associations between independent risk factors and MDRO infection. A total of 155 bacteria were collected from patients with MDROs infection and patients with non-MDROs infection, of which 66.5% were gram-positive bacteria and 33.5% were gram-negative. Staphylococcus aureus accounted for 26.5% of the 155 pathogens. MDROs, such as methicillin-resistant S. aureus and extended-spectrum β-lactamases-positive gram-negative bacillus, were detected after antibiotic treatment. Univariate analysis indicated that the number of antibiotics administered, being bedridden, repeat infection, operative time and repeated operation were different in the two groups. In addition, univariate logistic analysis indicated that being bedridden (OR, 3.98; P=0.001), administration of >2 antibiotics (OR, 2.42; P=0.026), an operative time of >3 h (OR, 3.37; P=0.003), repeated infection (OR, 3.08; P=0.009) and repetition of procedures (OR, 2.25; P=0.039) were individual risk factors for MDRO infection. Multivariate analysis showed that being bedridden (OR, 2.66; P=0.037), repeated infection (OR, 4.00; P=0.005) and an operative time of >3 h (OR, 2.28; P=0.023) were risk factors of MDRO infection. In conclusion, constrained antibiotic use, shortened operative time and increased activity duration can effectively prevent surgical-site infection with MDROs in patients with fractures.

Effectiveness of tailored screening for multidrug-resistant organisms upon admission to an intensive care unit in the United Arab Emirates.

Multidrug-resistant organism (MDRO) screening may identify high-risk patients for MDRO infection and curb the spread of these resistant pathogens. However, the heterogeneous practices in MDRO screening and the diversity of MDRO risk factors necessitate a tailored approach for successful implementation. This study aimed to evaluate the performance of tailored MDRO screening in predicting MDRO carriage compared to universal screening. Critically ill patients who underwent MDRO screening tests upon intensive care unit admission between September 2015 and December 2019 were included in the study. A risk-predicting model was developed using risk factors identified through multivariable logistic regression analysis. If an individual had one or more identified risk factors, the individual was deemed to be at risk of MDRO carriage and undergo tailored screening. The sensitivity of tailored screening was compared with universal screening for methicillin-resistant Staphylococcus aureus (MRSA)and multidrug-resistant Gram-negative bacilli (carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Enterobacterales). The use of tracheostomy or endotracheal tubes, previous antibiotic exposure, previous multidrug-resistant Gram-negative bacilli carriage history, admission to the medical department, peripheral vascular disease, and liver disease were associated with positive screening for multidrug-resistant Gram-negative bacilli. These six risk factors accounted for all positive screening for multidrug-resistant Gram-negative bacilli, requiring 38.6% of all tests. Notably, MRSA had different risk factor profiles, and the risk factor-based screening approach detected only 43.1% (31 out of 72) of MRSA-positive cases. Tailored screening based on identified risk factors showed variable sensitivities to individual MDROs compared to universal screening. A tailored screening approach for individual MDROs may enhance the overall effectiveness of MDRO screening programs.

A deep learning model for predicting multidrug-resistant organism infection in critically ill patients

BackgroundThis study aimed to apply the backpropagation neural network (BPNN) to develop a model for predicting multidrug-resistant organism (MDRO) infection in critically ill patients.MethodsThis study collected patient information admitted to the intensive care unit (ICU) of the Affiliated Hospital of Qingdao University from August 2021 to January 2022. All patients enrolled were divided randomly into a training set (80%) and a test set (20%). The least absolute shrinkage and selection operator and stepwise regression analysis were used to determine the independent risk factors for MDRO infection. A BPNN model was constructed based on these factors. Then, we externally validated this model in patients from May 2022 to July 2022 over the same center. The model performance was evaluated by the calibration curve, the area under the curve (AUC), sensitivity, specificity, and accuracy.ResultsIn the primary cohort, 688 patients were enrolled, including 109 (15.84%) MDRO infection patients. Risk factors for MDRO infection, as determined by the primary cohort, included length of hospitalization, length of ICU stay, long-term bed rest, antibiotics use before ICU, acute physiology and chronic health evaluation II, invasive operation before ICU, quantity of antibiotics, chronic lung disease, and hypoproteinemia. There were 238 patients in the validation set, including 31 (13.03%) MDRO infection patients. This BPNN model yielded good calibration. The AUC of the training set, the test set and the validation set were 0.889 (95% CI 0.852–0.925), 0.919 (95% CI 0.856–0.983), and 0.811 (95% CI 0.731–0.891), respectively.ConclusionsThis study confirmed nine independent risk factors for MDRO infection. The BPNN model performed well and was potentially used to predict MDRO infection in ICU patients.

Risk Factors for Post-Operative Multi-Drug-Resistant Organism Bacterial Infection in Patients With Stanford Acute Type A Aortic Dissection.

Background: To explore the risk factors for multi-drug-resistant organism (MDRO) infection in patients with Stanford acute type A aortic dissection (ATAAD). We conducted a retrospective cohort study using the data of post-operative patients with ATAAD in our hospital. Patients and Methods: This study included 82 post-operative patients with ATAAD in the past decade. They were divided into a MDRO group (n = 31) and a non-MDRO group (n = 51) according to whether they had acquired multi-drug-resistant (MDR) bacterial infection. Multivariable logistic regression was used to analyze the risk factors for MDR infections in patients with ATAAD. Results: The incidence of multi-drug-resistant bacterial infection was 37.80%. Seventeen factors, including hospital stay (p = 0.007), utilization of third-generation cephalosporins (p = 0.0068), antibiotic species of exposure (p = 0.0002), leukocyte-depleted red blood cell suspension dosage (p < 0.0001), fresh frozen plasma dosage (p < 0.0001), application of blood purification (p = 0.0493), and the total antibiotic days of exposure (p = 0.0001) diverged between the two groups (all p < 0.05). The logistic regression analysis revealed that the utilization of third-generation cephalosporins (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.01-5.33; p = 0.0478), antibiotic species of exposure (OR, 5.76; 95% CI, 1.45-22.83; p = 0.0128), leukocyte-depleted red blood cell suspension dosage (OR, 12.43; 95% CI, 2.71-57.07; p = 0.0012), and fresh frozen plasma dosage (OR, 5.05; 95% CI, 1.18-21.56; p = 0.0286) were independent variables for MDRO infections. Among the 23 drug-resistant bacteria detected, Acinetobacter baumannii was the main pathogen. Conclusions: Our study shows that the utilization of third-generation cephalosporins, antibiotic species of exposure, leukocyte-depleted red blood cell suspension dosage, and fresh frozen plasma dosage were independent risk factors for post-operative multi-drug-resistant infection in patients with ATAAD. Acinetobacter baumannii occupied the largest share of resistant bacteria that induce infection in post-operative patients with ATAAD.

The Prevalence of Multidrug-Resistant Organisms in Patients with Surgical Site Infections in Riyadh, Saudi Arabia: A Cross-sectional Study at a Tertiary Care Hospital

Background: Multidrug-resistant (MDR) infections are a threat in patients undergoing surgery. This study was undertaken to determine the prevalence and possible predictors of MDR infections over a two-year period in patients with surgical site infection (SSI) at a tertiary care hospital in Riyadh, Saudi Arabia. Methods: We conducted a cross-sectional study from April 2016 to April 2018 by reviewing hospital records of patients with a diagnosis of SSI based on a physician report and laboratory findings. The isolation of MDR organisms (MDRO) from SSI was the primary outcome variable as well as other risk factors. Results: SSI was diagnosed in 55 out of 77 patients under study, with MDRO prevalence rate of 44%. Previous antibiotic use and hospitalization in the last 90 days were strongly associated with developing MDRO infection often due to ESBL producing Gram-negative bacterial pathogens. Superficial and deep incisional SSI were more frequent in patients compared to organ/space SSI. History of diabetes mellitus, duration of surgery and bacterial colonization at other body site also increased the likelihood of MDRO. Factors such as trauma, obesity, general anesthesia, and wound types were not found to increase the risk for MDRO. Conclusions: Our study identified recent antibiotic use and hospitalization as major risk factors for MDRO surgical site infections. Other predisposing factors include diabetes mellitus, duration of surgery and bacterial colonization. MDRO isolated include E. coli and Pseudomonas aeruginosa. Bacterial pathogens harboring multiple resistant mechanisms can complicate SSI adversely affecting clinical outcomes following routine surgical procedures.

Development and Validation of a Nomogram Prediction Model for Multidrug-Resistant Organisms Infection in a Neurosurgical Intensive Care Unit.

To develop a predictive model for assessing the risk of multidrug-resistant organisms (MDROs) infection and validate its effectiveness. Logistic regression analysis revealed that sex, hospitalization time, febrile time, invasive operations, postoperative prophylactic use of antibiotics, mechanical ventilator time, central venous catheter indwelling time, urethral catheter indwelling time, ALB, PLT, WBC, and L% were independent predictors of MDROs infection in the NICU. The area under the ROC curve for the training set and validation set were 0.880 (95% CI: 0.857-0.904) and 0.831 (95% CI: 0.786-0.876), respectively. The model's prediction curve closely matched the ideal curve, indicating excellent predictive performance. The prediction model developed in this study demonstrates good accuracy in assessing the risk of MDROs infection. It serves as a valuable tool for neurosurgical intensive care practitioners, providing an objective means to effectively evaluate and target the risk of MDROs infection.

Effectiveness of Preventive Nursing Program for Multidrug-Resistant Organism Transmission: A Quasi-experimental Study

         Multidrug-resistant organism infections are a major public health problem. Promoting nurses’ practice in preventing multidrug-resistant infections can reduce hospital transmission. This quasi-experimental study investigated the effectiveness of a preventive nursing program for multidrug-resistant organism transmission. The study was carried out in the Department of Internal Medicine in a tertiary hospital in south Thailand. Participants in this study were registered nurses. Two wards were randomly selected as the experimental ward and two as the control ward, then participants from each ward were purposively selected. Finally, there were 60 participants, n = 31 from the experiment wards and n = 29 from the control wards. The experimental group received a 4-week program, whereas the control group followed the usual practice. Then, the practices in preventing multidrug-resistant organism transmission of the experimental and control groups were assessed 4 and 12 weeks after the program ended. The instruments for data collection included a demographic data form and a preventive practice observation form. Data were analyzed using descriptive statistics and a chi-square test.         The results showed that, at 4 and 12 weeks after completion of the program, nurses in the experimental group had a significantly higher proportion of correct practices (hand hygiene, use of personal protective equipment, patient placement, patient transport, patient care equipment management, environmental management, and linen and infectious waste management of multidrug-resistant organism transmission) than before receiving the program and in the control group. The findings suggest that the program effectively improves nurses’ correct practices in preventing multidrug-resistant organism transmission. The program can be applied to promote and support preventive practices among nurses. However, long-term follow-ups with the incidence of multidrug-resistant organism transmission should be further studied. In addition, as this study was conducted with nurses working in the internal medicine wards of a tertiary hospital, it is necessary to evaluate the program's effectiveness with different samples prior to its widerimplementation.