Reduction of Environmental Contamination With Multidrug-Resistant Bacteria by Copper-Alloy Coating of Surfaces in a Highly Endemic Setting.

OBJECTIVE To evaluate the efficacy of copper-coating in reducing environmental colonization in an intensive-care unit (ICU) with multidrug-resistant-organism (MDRO) endemicity DESIGN Interventional, comparative crossover trial SETTING The general ICU of Attikon University hospital in Athens, Greece PATIENTS Those admitted to ICU compartments A and B during the study period METHODS Before any intervention (phase 1), the optimum sampling method using 2 nylon swabs was validated. In phase 2, 6 copper-coated beds (ie, with coated upper, lower, and side rails) and accessories (ie, coated side table, intravenous [i.v.] pole stands, side-cart handles, and manual antiseptic dispenser cover) were introduced as follows: During phase 2a (September 2011 to February 2012), coated items were placed next to noncoated ones (controls) in both compartments A and B; during phase 2b (May 2012 to January 2013), all copper-coated items were placed in compartment A, and all noncoated ones (controls) in compartment B. Patients were randomly assigned to available beds. Environmental samples were cultured quantitatively for clinically important bacteria. Clinical and demographic data were collected from medical records. RESULTS Copper coating significantly reduced the percentage of colonized surfaces (55.6% vs 72.5%; P<.0001), the percentage of surfaces colonized by MDR gram-negative bacteria (13.8% vs 22.7%; P=.003) or by enterococci (4% vs 17%; P=.014), the total bioburden (2,858 vs 7,631 cfu/100 cm2; P=.008), and the bioburden of gram-negative isolates, specifically (261 vs 1,266 cfu/100 cm2; P=.049). This effect was more pronounced when the ratio of coated surfaces around the patient was increased (phase 2b). CONCLUSIONS Copper-coated items in an ICU setting with endemic high antimicrobial resistance reduced environmental colonization by MDROs. Infect Control Hosp Epidemiol 2017;38:765-771.

Nationwide surveillance of resistance rates of Staphylococcus aureus clinical isolates from Greek hospitals, 2012-2013.

Purpose To evaluate the in vitro efficacy of several anti-staphylococcal agents against a nationwide collection of contemporary Staphylococcus aureus clinical isolates from several healthcare centres in Greece. Methods Thirty hospitals throughout Greece (18 in Attica) provided all clinical isolates of S.aureus from April 2012 to May 2013 to a central lab to be re-submitted to susceptibility testing. The MICs were evaluated by Vitek® 2 with the exception of ceftaroline (OXOID M.I.C. Evaluator™). Vancomycin and daptomycin MICs were also evaluated by Etest®. Heterogeneously vancomycin-intermediate strains (hVISA) were detected by the Etest® GRD. VISA phenotype was confirmed by PAP-AUC. Results A total of 1005 isolates (39% MRSA) were studied. Susceptibility rates were: erythromycin 66.5%, clindamycin 79.2%, SXT 98.9%, rifampicin 97.3%, fusidic acid 67%, moxifloxacin 78.8%, vancomycin 99.9%, ceftaroline 92.9% and linezolid, tigecycline and daptomycin 100%. For mupirocin, high level resistance could be excluded for 98.9% of isolates. Vancomycin Etest® MIC50/90 were 1.5/1.5 mg/L, 58.5% of isolates exhibited a MIC > 1 and 8.7% a MIC of 2 mg/L, while Vitek® MIC50/90 were 1/1 and 3.1% showed MIC > 1 mg/L. One VISA strain was detected. Among the selected 175 isolates that were screened for hVISA phenotype, six (3.4%) were positive. In 315 bloodstream isolates, 64.1% had a vancomycin Etest® MIC > 1 mg/L. Conclusions This multi-centre surveillance study revealed that a significant percentage of contemporary S.aureus isolates from Greek patients have a vancomycin MIC (> 1 mg/L) that may compromise the clinical efficacy of the drug for the treatment of serious infections. The in vitro activity of SXT, rifampicin, mupirocin, linezolid, tigecycline, daptomycin and ceftaroline remains excellent.

Mycobacterium abscessus Complex Identification with Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry.

We determined that the Vitek MS Plus matrix-assisted laser desorption ionization-time of flight mass spectrometry using research-use-only (RUO) v.4.12 and in vitro-diagnostic (IVD) v.3.0 databases accurately identified 41 Mycobacterium abscessus subsp. abscessus and 13 M. abscessus subsp. massiliense isolates identified by whole-genome sequencing to the species but not the subspecies level, from Middlebrook 7H11 and Burkholderia cepacia selective agars. Peak analysis revealed three peaks potentially able to differentiate between subspecies.

Antimicrobial activity of copper surfaces against carbapenemase-producing contemporary Gram-negative clinical isolates.

OBJECTIVES: The antimicrobial activity of copper surfaces against a variety of contemporary carbapenemase-producing Gram-negative bacteria representative of the most problematic nosocomial pathogens worldwide was evaluated. METHODS: Twenty-four clinical isolates, comprising four of Escherichia coli, two of Enterobacter spp., eight of Klebsiella pneumoniae and five each of Pseudomonas aeruginosa and Acinetobacter baumannii producing either VIM-1 and/or KPC-2 or VIM-2 or OXA-type carbapenemases, were studied. The antimicrobial activity of 99% copper (Cu99%) and a 63% alloy (Cu63%) was evaluated in comparison with that of stainless steel (SS) and polyvinylchloride (PVC) by incubating ∼10(6) cfu/cm(2) of the tested strains on each surface at room temperature. RESULTS: Copper demonstrated antimicrobial activity against all studied isolates. This effect was observed earlier and was more pronounced for Cu99% than for Cu63%. Cu99% showed a bactericidal effect after <2 h for A. baumannii, 3 h for Enterobacter spp., 5 h for K. pneumoniae and 6 h for P. aeruginosa and E. coli. No viable colonies were recovered from five (20.8%) isolates after 3 h and from nine (37.5%) isolates after 5 h of incubation on Cu99%. CONCLUSIONS: Copper has significant antimicrobial activity against multidrug-resistant nosocomial Gram-negative pathogens. This supports the hypothesis that replacement of high-contact materials with copper could reduce the high burden of environmental contamination around high-risk patients. However, this strategy should be seen as an adjunctive measure to established cleaning protocols and to good hygiene practices for prevention of hospital-acquired infections.

In vivo transmission of a plasmid containing the KPC-2 gene in a single patient.

Here we describe a case of in vivo horizontal interspecies transmission of a KPC-2-producing plasmid from a Klebsiella pneumoniae to an Enterobacter aerogenes strain in the same patient. The patient's gut flora initially contained a carbapenem-susceptible E. aerogenes strain and 10 days after admission a KPC-2-positive K. pneumoniae. Three months after admission, a KPC-2-positive E. aerogenes was identified in fecal surveillance cultures. This isolate was isogenic with the initial E. aerogenes and contained a KPC-2-coding plasmid identical to that of the K. pneumoniae. The patient developed bacteraemia by the KPC-2-positive K. pneumoniae 17 days after her first colonization. In vivo horizontal transmission of blaKPC-carrying plasmids between bacterial species underscores the importance of antibiotic stewardship along with implementation of infection control measures for the containment of KPC-producers.

Activity of plazomicin (ACHN-490) against MDR clinical isolates of Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. from Athens, Greece.

The in vitro activity of plazomicin was evaluated against 300 multidrug resistant (MDR) (carbapenemase and/or ESBL-producing) isolates from four hospitals in Athens, an area where carbapenemase-producing organisms are endemic. Most of the isolates were also resistant to the legacy aminoglycosides with the MIC50/MIC90 to tobramycin, amikacin and gentamicin being 32/>32, 32/>32 and 4/>8 µg/ml, respectively. ACHN-490 retained activity (MICs ≤ 4 µg/ml) against all isolates of Klebsiella pneumoniae, Escherichia coli, and Enterobacter spp. tested with MIC50 and MIC90 of 1 and 2 µg/ml, respectively, irrespective of their MDR phenotype and it represents a promising alternative for the treatment of the most problematic Gram-negative pathogens.

Comparison of direct antimicrobial susceptibility testing methods for rapid analysis of bronchial secretion samples in ventilator-associated pneumonia.

Two hundred and fifty tracheal aspirates were subjected to direct antimicrobial susceptibility testing by disk diffusion, Etest and inoculation on antibiotic-enriched MacConkey agar plates. Results were compared with those obtained using an automated system on microorganisms recovered from standard quantitative culture. A total of 255 microorganisms were isolated from 194 positive samples by the standard quantitative procedure. A total of 85.1%, 82.5% and 72.5% agreement between direct disk diffusion, Etest and antibiotic-enriched MacConkey agar plates, respectively, and the standard procedure was observed in 64 microorganisms obtained from monomicrobial cultures that corresponded to 240 individual microorganism-antimicrobial agent combinations. Three (1.3%) and four (1.7%) very major errors for direct disk diffusion and Etest methods were observed, respectively. The antibiotic-enriched MacConkey agar plate method compared with the standard procedure demonstrated an unacceptable rate of very major (6.7%) and major errors (14.2%). Clinical evaluation of direct susceptibility tests based on the speculative impact on clinical practice by guiding patient's early treatment, if all positive cultures corresponded to infection, was correct in 79.9% for the direct disk diffusion test, 77.8% for the direct Etest method and 68.0% for antibiotic-enriched MacConkey agar plates. Direct diffusion tests (Etest or disk diffusion) applied on respiratory samples are rapid techniques that provide results comparable with standard antimicrobial susceptibility testing in <24 h.

In vitro interactions of antimicrobial combinations with fosfomycin against KPC-2-producing Klebsiella pneumoniae and protection of resistance development.

Using time-kill methodology, we investigated the interactions of fosfomycin with meropenem or colistin or gentamicin against 17 genetically distinct Klebsiella pneumoniae clinical isolates carrying blaKPC-2. Synergy was observed with meropenem or colistin against 64.7 and 11.8% of tested isolates, while the combination with gentamicin resulted in indifference. All studied combinations showed improved bactericidal activity, compared to fosfomycin alone and prevented the development of fosfomycin resistance in 69.2, 53.8, and 81.8% of susceptible isolates, respectively.

Evaluation of CHROMagar™ KPC for the detection of carbapenemase-producing Enterobacteriaceae in rectal surveillance cultures.

In this study, the performance of the chromogenic medium CHROMagar™ KPC was evaluated and was compared with in-house-daily prepared McConkey agar plates supplemented with imipenem (1 mg/L) for the detection of carbapenemase-producing Enterobacteriaceae. In this surveillance study, rectal swabs were cultured on both media and polymerase chain reaction (PCR) for bla(KPC) and bla(VIM) was used to confirm the genotype of growing colonies of Enterobacteriaceae. CHROMagar KPC was also tested with 17 genotypically characterised carbapenemase-producing and non-producing Gram-negative bacteria. It was shown that CHROMagar allows rapid detection of carbapenemase-producing Enterobacteriaceae, although bla(KPC)- and bla(VIM)-harbouring isolates could not be differentiated by colour or colony morphology. The positive and negative predictive values of the tested methods for the detection of carbapenemase-producing Enterobacteriaceae were, respectively, 100% and 98.8% for CHROMagar KPC and 94.7% and 88.6% for imipenem-supplemented McConkey agar. CHROMagar KPC medium is a useful screening medium for carbapenemase-producing Enterobacteriaceae in stools in settings with a high proportion of patients colonised with a variety of carbapenemase-producers.

An outbreak of infection due to beta-Lactamase Klebsiella pneumoniae Carbapenemase 2-producing K. pneumoniae in a Greek University Hospital: molecular characterization, epidemiology, and outcomes.

BACKGROUND: We describe the emergence and spread of Klebsiella pneumoniae carbapenemase 2 (KPC-2)-producing K. pneumoniae at a Greek University hospital. METHODS: Isolates with a carbapenem minimum inhibitory concentration >1 microg/mL and a negative EDTA-imipenem disk synergy test result were submitted to boronic acid disk test and to polymerase chain reaction (PCR) for KPC gene and sequencing. Records from patients who had KPC-2-producing K. pneumoniae isolated were retrospectively reviewed. Clinical isolates were submitted to molecular typing using pulsed-field gel electrophoresis, and the beta-lactamase content was studied using isoelectric focusing and PCR. RESULTS: From January 2007 through December 2008, 50 patients (34 in the intensive care unit [ICU]) were colonized (n = 32) or infected (n = 18) by KPC-2-producing K. pneumoniae. Increasing prevalence of KPC-2-producing K. pneumoniae coincided with decreasing prevalence of metallo-beta lactamase-producing isolates in our ICU. Multidrug resistance characterized the studied isolates, with colistin, gentamicin, and fosfomycin being the most active agents. Besides KPC-2, clinical isolates encoded TEM-1-like, SHV-11, SHV-12, CTX-M-15, and LEN-19 enzymes. Four different clonal types were detected; the predominant one comprised 41 single patient isolates (82%). Sporadic multiclonal cases of KPC-2-producing K. pneumoniae infection were identified from September 2007 through May 2008. The outbreak strain was introduced in February 2008 and disseminated rapidly by cross-transmission; 38 patients (76%) were identified after August 2008. Fourteen cases of bacteremia, 2 surgical site infections, 2 lower respiratory tract infections (1 bacteremic), and 1 urinary tract infection were identified. Most patients received a colistin-containing combination treatment. Crude mortality was 58.8% among ICU patients and 37.5% among non-ICU patients, but attributable mortality was 22.2% and 33.3%, respectively. CONCLUSIONS: The emergence of KPC-2-producing K. pneumoniae in Greek hospitals creates an important challenge for clinicians and hospital epidemiologists, because it is added to the already high burden of antimicrobial resistance.