Interprofessional education in antimicrobial stewardship, a collaborative effort.

Introduction: Antimicrobial stewardship (AMS) education and interprofessional collaboration are integral to the success of a stewardship programme. An interactive interprofessional AMS workshop, designed to encourage workplace interprofessional collaboration was piloted in a tertiary hospital. Objectives: To obtain feedback to determine the suitability and sustainability of the AMS workshop. Methods: Feedback was elicited through a predesigned questionnaire containing both open-ended and closed questions on the content and structure of the workshop. Results: The survey had a 70% (n = 16) overall response rate. All participants agreed that the goals of the workshop were met and that the knowledge and skills gained from the workshop would help them in their AMS roles. All participants indicated that the workshop content, and the level at which it was pitched, met their expectations and that it had improved their knowledge and skills. All agreed that they found it advantageous and enjoyed learning as an interprofessional group. Open feedback showed that the workshop was found to be useful and would potentially result in improved patient care, dissemination of knowledge, improved teamwork and organizational culture. Conclusions: The positive feedback and changes made following the workshop demonstrated that a targeted AMS educational workshop adds value to an antimicrobial stewardship programme.

Antimicrobial susceptibility of bacterial uropathogens in a South African regional hospital.

Background: Urinary tract infections are common bacterial infections affecting millions worldwide. Although treatment options for urinary tract infections are well established, with ciprofloxacin long considered one of the antibiotics of choice, increasing antibiotic resistance may delay the initiation of appropriate therapy. While this increase in antimicrobial resistance has been demonstrated in multiple studies around the world, there is a dearth of information from developing countries. Objective: This study aimed to describe the antimicrobial susceptibility patterns of commonly isolated bacterial uropathogens in a South African hospital. Methods: Antimicrobial susceptibility data of isolates obtained from urine specimens at the RK Khan Hospital, a regional hospital in KwaZulu-Natal, South Africa, between January 2018 and December 2020 were retrieved from the hospital's laboratory information system and analysed to determine the differences in resistance rates between the most frequently isolated bacterial uropathogens. Results: Of the 3048 bacterial urinary pathogens isolated between 2018 and 2020, Escherichia coli (1603; 53%) was the most common, followed by Klebsiella spp. (437; 14%). Both E. coli and Klebsiella spp. showed high rates of resistance to amoxicillin/clavulanic acid (29.8% and 42.3%) and ciprofloxacin (37.7% and 30.4%). Nitrofurantoin resistance was low among E. coli (6.2%) but high among Klebsiella spp. (61.3%). Conclusion: E. coli and Klebsiella spp. in this study were highly resistant to amoxicillin/clavulanic acid and ciprofloxacin, two of the frequently prescribed oral treatment options. What this study adds: This study highlights the importance of regular local antimicrobial resistance surveillance to inform appropriate empiric therapy.

Consequences of rpoB mutations missed by the GenoType MTBDRplus assay in a programmatic setting in South Africa.

Background: Rifampicin resistance missed by commercial rapid molecular assays but detected by phenotypic assays may lead to discordant susceptibility results and affect patient management. Objective: This study was conducted to evaluate the causes of rifampicin resistance missed by the GenoType MTBDRplus and its impact on the programmatic management of tuberculosis in KwaZulu-Natal, South Africa. Methods: We analysed routine tuberculosis programme data from January 2014 to December 2014 on isolates showing rifampicin susceptibility on the GenoType MTBDRplus assay but resistance on the phenotypic agar proportion method. Whole-genome sequencing was performed on a subset of these isolates. Results: Out of 505 patients with isoniazid mono-resistant tuberculosis on the MTBDRplus, 145 (28.7%) isolates showed both isoniazid and rifampicin resistance on the phenotypic assay. The mean time from MTBDRplus results to initiation of drug-resistant tuberculosis therapy was 93.7 days. 65.7% of the patients had received previous tuberculosis treatment. The most common mutations detected in the 36 sequenced isolates were I491F (16; 44.4%) and L452P (12; 33.3%). Among the 36 isolates, resistance to other anti-tuberculosis drugs was 69.4% for pyrazinamide, 83.3% for ethambutol, 69.4% for streptomycin, and 50% for ethionamide. Conclusion: Missed rifampicin resistance was mostly due to the I491F mutation located outside the MTBDRplus detection area and the L452P mutation, which was not included in the initial version 2 of the MTBDRplus. This led to substantial delays in the initiation of appropriate therapy. The previous tuberculosis treatment history and the high level of resistance to other anti-tuberculosis drugs suggest an accumulation of resistance.

Detection of metronidazole resistance in Trichomonas vaginalis using uncultured vaginal swabs.

Trichomonas vaginalis (T. vaginalis) is the most prevalent sexually transmitted infection (STI) globally. Metronidazole is the drug of choice for treating T. vaginalis infections although metronidazole-resistant T. vaginalis has been reported in clinical isolates. The purpose of this study was to determine the presence of mutations in nitroreductase genes associated with metronidazole resistance in vaginal swabs testing positive for T. vaginalis. This study included 385 human immunodeficiency virus (HIV)-positive pregnant women. Vaginal swabs were collected from consenting pregnant women and used for the detection of T. vaginalis using the TaqMan assay. From the vaginal swabs, nitroreductase genes ntr4 and ntr6 containing mutations associated with metronidazole resistance were amplified using a quantitative polymerase chain reaction (PCR) assay. To validate the PCR assay, T. vaginalis cultured isolates with known metronidazole resistance profiles were used as controls in the mutation detection assays. The prevalence of T. vaginalis in the study population was 12.2% (47/385). Mutations associated with resistance to metronidazole were detected in more than 40% of the samples tested, i.e. 21/47 (45%) and 24/47 (51%) for ntr4 and ntr6, respectively. A total of 19 samples (40%) carried mutations for both ntr4 and ntr6 genes associated with metronidazole resistance. The validation assays showed a positive correlation between phenotypic and genotypic resistance profiles. This study found a high prevalence of mutations associated with metronidazole resistance. This is concerning since metronidazole is currently used in the syndromic management of STIs in South Africa. Molecular-based assays for monitoring metronidazole resistance profiles using nitroreductase genes may serve as a feasible method for antimicrobial surveillance studies for T. vaginalis.

Significant Associations between Chlamydia trachomatis and Neisseria gonorrhoeae Infections in Human Immunodeficiency Virus-Infected Pregnant Women.

There is a lack of data on the burden of Chlamydia trachomatis and Neisseria gonorrhoeae among human immunodeficiency virus- (HIV-) infected pregnant women in South Africa. We conducted a cross-sectional study which included 385 HIV-infected pregnant women attending antenatal clinic at the King Edward VIII Hospital in Durban, South Africa. The women provided vaginal swabs which were tested for C. trachomatis and N. gonorrhoeae. The prevalence of the individual STIs was as follows: C. trachomatis (47/385, 12.2%) and N. gonorrhoeae (16/385, 4.1%). Having a circumcised partner, testing positive for N. gonorrhoeae, and perceiving themselves of being at risk for infection were shown to increase the risk for C. trachomatis infection. Without controlling for the other factors, testing positive for N. gonorrhoeae increased the risk for C. trachomatis infection by 10-fold (OR: 10.17, 95% CI: 3.39-29.66, p < 0.001). Similarly, adjusting for the other factors, the risk for C. trachomatis infection in women who tested positive for N. gonorrhoeae was 9-fold (OR: 9.16, 95% CI: 2.19-40.18, p = 0.003). The following factors were associated with the increased risk of N. gonorrhoeae infection: not knowing their partner's HIV status, partner having other partners, and C. trachomatis infection status. Without controlling for the other factors, testing positive for C. trachomatis increased the risk for N. gonorrhoeae infection by 6-fold (OR: 6.52, 95% CI: 2.22-18.49, p < 0.001). Similarly, adjusting for the other factors, the risk for N. gonorrhoeae infection in women who tested positive for C. trachomatis was 6-fold (OR: 6.09, 95% CI: 1.73-22.03, p = 0.005). We found a significant association between C. trachomatis and N. gonorrhoeae in the pregnant women and the risk factors associated with these pathogens. Future studies are urgently required to investigate the impact of C. trachomatis/N. gonorrhoeae coinfections in HIV pregnant women since this data is lacking in our setting. In addition, etiological screening of C. trachomatis and N. gonorrhoeae during antenatal clinic is urgently required to prevent adverse pregnancy and birth outcomes associated with these infections.

High-Resolution Melting Analysis to Detect Antimicrobial Resistance Determinants in South African Neisseria gonorrhoeae Clinical Isolates and Specimens.

BACKGROUND: Antimicrobial resistance is limiting treatment options for Neisseria gonorrhoeae infections. To aid or replace culture and the syndromic management approach, molecular assays are required for antimicrobial susceptibility testing to guide appropriate and rapid treatment. OBJECTIVE: We aimed to detect single-nucleotide polymorphisms and plasmids associated with antimicrobial resistance from N. gonorrhoeae isolates from a clinic population in South Africa, using real-time PCR as a rapid test for AMR detection. METHODS: N. gonorrhoeae isolates, from female and male patients presenting for care at a sexually transmitted infections clinic in Durban, South Africa, were analysed using phenotypic and genotypic methods for identification and antibiotic susceptibility testing (AST). Real-time PCR and high-resolution melting analysis were used to detect porA pseudogene (species-specific marker) and resistance-associated targets. Whole-genome sequencing was used as the gold standard for the presence of point mutations. RESULTS: The real-time porA pseudogene assay identified all N. gonorrhoeae-positive isolates and specimens. Concordance between molecular detection (real-time PCR and HRM) and resistance phenotype was ≥92% for bla TEM (HLR penicillin), rpsJ_V57M (tetracycline), tetM (tetracycline), and gyrA_S91F (ciprofloxacin). Resistance determinants 16SrRNA_C1192U (spectinomycin), mtrR_G45D (azithromycin), and penA_D545S, penA_mosaic (cefixime/ceftriaxone) correlated with the WHO control isolates. CONCLUSIONS: Eight resistance-associated targets correlated with phenotypic culture results. The porA pseudogene reliably detected N. gonorrhoeae. Larger cohorts are required to validate the utility of these targets as a convenient culture-free diagnostic tool, to guide STI management in a South African population.

Case Report: Human Bertiellosis-A Rare Cestode Infection in a South African Child.

Cestodes of Bertiella genus are parasites of nonhuman primates. We describe a rare case of human bertiellosis in South Africa: a 3-year-old girl with a 1-year history of rectal proglottid discharge and intermittent abdominal pain. After repeated failure with benzimidazole antihelminthic treatment, praziquantel proved successful.

Assessing a diagnosis tool for bacterial vaginosis.

Diagnosis of bacterial vaginosis (BV) in resource-poor settings relies on semiquantitative microscopy algorithm such as the Nugent score (NS). We evaluated a quantitative real-time PCR (qPCR) assay to detect and quantify individual BV-associated bacterial communities. Vaginal swabs from 247 South African women attending an STI clinic were evaluated for BV using NS. We used qPCR to analyze DNA from vaginal swabs for eight BV-associated bacteria, Gardnerella vaginalis (GV), Prevotella bivia (PB), BV-associated bacteria 2 (BVAB2), Megasphaera-1 (M-1), Atopobium vaginae (AV), Lactobacillus crispatus (LC), Lactobacillus jensenii (LJ), and Lactobacillus iners (LI). Sensitivities and specificities were generated for each qPCR assay. Using a ROC analysis, cutoffs were calculated for each bacterial species. A logistic regression model was used to determine the strongest predictors of BV status. Nugent scores indicated 35.6% of patients harbor BV-associated flora (NS 7-10). AV, GV, GAMB (GV + AV + M-1 + BVAB2), and LC + LJ showed the highest AUC, sensitivities, and specificities (listed respectively): AV (0.96; 96%; 93%), GV (0.88; 78%; 79%), GAMB (0.9; 87%; 82%), and LC + LJ (0.84; 82%; 72%) (all p < 0.05). Increased GAMB copies (effect = 0.15, p = 0.01) and decreased LC + LJ copies (effect = - 0.26, p < 0.0001) demonstrated the strongest association with higher BV scoring. Scoring of BV did not differ across our qPCR assay when compared to the commercial BD MAX® and the gold standard Nugent scores. We developed an accurate assay, which has the potential to be used as a BV diagnosis tool that is cost-effective and has the potential to be utilized in a resource limited setting.

Genomic Analysis of Carbapenemase-Producing Extensively Drug-Resistant Klebsiella pneumoniae Isolates Reveals the Horizontal Spread of p18-43_01 Plasmid Encoding blaNDM-1 in South Africa.

Whole-genome sequence (WGS) analyses were employed to investigate the genomic epidemiology of extensively drug-resistant Klebsiella pneumoniae strains, focusing on the carbapenem resistance-encoding determinants, mobile genetic support, clonal and epidemiological relationships. A total of ten isolates were obtained from patients admitted to the intensive care unit (ICU) in a public hospital in South Africa. Five isolates were from rectal swabs of colonized patients and five from blood cultures of patients with invasive carbapenem-resistant infections. Following microbial identification and antibiotic susceptibility tests, the isolates were subjected to WGS on the Illumina MiSeq platform. All the isolates showed genotypic resistance to tested ß-lactams (NDM-1, OXA-1, CTX-M-15, TEM-1B, SHV-1) and other antibiotics. All but one isolate belonged to the ST152 with a novel sequence type, ST3136, differing by a single-locus variant. The isolates had the same plasmid multilocus sequence type (IncF[K12:A-:B36]) and capsular serotype (KL149), supporting the epidemiological linkage between the clones. Resistance to carbapenems in the 10 isolates was conferred by the blaNDM-1 mediated by the acquisition of multi-replicon [ColRNAI, IncFIB(pB171), Col440I, IncFII, IncFIB(K) and IncFII(Yp)] p18-43_01 plasmid. These findings suggest that the acquisition of blaNDM-1-bearing plasmid structure (p18-43_01), horizontal transfer and clonal dissemination facilitate the spread of carbapenemases in South Africa. This emphasizes the importance of targeted infection control measures to prevent dissemination.

South African Society of Clinical Microbiology Clostridioides difficile infection diagnosis, management and infection prevention and control guideline.

Clostridioides difficile infection (CDI) is a problem in both developed and developing countries and is a common hospital-acquired infection. This guideline provides evidence-based practical recommendations for South Africa and other developing countries. The scope of the guideline includes CDI diagnostic approaches; adult, paediatric and special populations treatment options; and surveillance and infection prevention and control recommendations.

Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients.

BACKGROUND: Ventilator-associated pneumonia (VAP) has recently been classified as possible or probable. Although direct attributable mortality has been difficult to prove, delay in instituting appropriate therapy has been reported to increase morbidity and mortality. Recent literature suggests that in possible VAP, instituting directed therapy while awaiting microbiological culture does not prejudice outcome compared with best-guess empirical therapy. OBJECTIVES: To ascertain outcomes of directed v. empirical therapy in possible and probable VAP, respectively. METHODS: Endotracheal aspirates were obtained from patients with suspected VAP. Those considered to have possible VAP were given directed therapy following culture results, whereas patients with more convincing evidence of VAP were classed as having probable VAP and commenced on empirical antimicrobials based on microbiological surveillance. RESULTS: Pneumonia was suspected in 106 (36.8%) of 288 patients admitted during January - December 2014. Of these, 13 did not fulfil the criteria for VAP. Of the remaining 93 (32.2%), 31 (33.3%) were considered to have probable and 62 (66.7%) possible VAP. The former were commenced on empirical antimicrobials, with 28 (90.3%) receiving appropriate therapy. Of those with possible VAP, 34 (54.8%) were given directed therapy and in 28 (45.2%) no antimicrobials were prescribed. Of the latter, 24 recovered without antimicrobials and 4 died, 3 from severe traumatic brain injury and 1 due to overwhelming intra-abdominal sepsis. No death was directly attributable to failure to treat VAP. No significant difference in mortality was found between the 34 patients with possible VAP who were commenced on directed therapy and the 31 with probable VAP who were commenced on empirical antimicrobials (p=0.75). CONCLUSIONS: Delaying antimicrobial therapy for VAP where clinical doubt exists does not adversely affect outcome. Furthermore, this policy limits the use of antimicrobials in patients with possible VAP following improvement in their clinical condition despite no therapy.

National sentinel site surveillance for antimicrobial resistance in Klebsiella pneumoniae isolates in South Africa, 2010 - 2012.

BACKGROUND: The increasing rates of antimicrobial resistance observed in the nosocomial pathogen Klebsiella pneumoniae are of major public health concern worldwide. OBJECTIVES: To describe the antibiotic susceptibility profiles of K. pneumoniae isolates from bacteraemic patients submitted by sentinel laboratories in five regions of South Africa from mid-2010 to mid-2012. Molecular methods were used to detect the most commonly found extended-spectrum beta-lactamase (ESBL) and carbapenemase resistance genes. METHODS: Thirteen academic centres serving the public healthcare sector in Gauteng, KwaZulu-Natal, Free State, Limpopo and Western Cape provinces submitted K. pneumoniae isolates from patients with bloodstream infections. Vitek 2 and MicroScan instruments were used for organism identification and susceptibility testing. Multiplex polymerase chain reactions (PCRs) were used to detect blaCTX-M, blaSHV and blaTEM genes in a proportion of the ESBL isolates. All isolates exhibiting reduced susceptibility to carbapenems were PCR tested for blaKPC and blaNDM-1 resistance genes. RESULTS: Overall, 68.3% of the 2,774 isolates were ESBL-positive, showing resistance to cefotaxime, ceftazidime and cefepime. Furthermore, 46.5% of all isolates were resistant to ciprofloxacin and 33.1% to piperacillin-tazobactam. The major ESBL genes were abundantly present in the sample analysed. Most isolates (95.5%) were susceptible to the carbapenems tested, and no isolates were positive for blaKPC or blaNDM-1. There was a trend towards a decrease in susceptibility to most antibiotics. CONCLUSION: The high proportion of ESBL-producing K. pneumoniae isolates observed, and the prevalence of ESBL genes, are of great concern. Our findings represent a baseline for further surveillance in SA, and can be used for policy and treatment decisions.

Microbiological surveillance and antimicrobial stewardship minimise the need for ultrabroad-spectrum combination therapy for treatment of nosocomial infections in a trauma intensive care unit: an audit of an evidence-based empiric antimicrobial policy.

BACKGROUND: Nosocomial infections are a major cause of morbidity in the critically injured, and the incidence of resistant strains of bacteria is increasing. Management requires a strategy that achieves accurate empiric cover without antibiotic overuse - a goal that may be achieved by surveillance and antibiotic stewardship. OBJECTIVES: With the aim of minimising the use of empirical ultrabroad-spectrum combination antimicrobial prescriptions and reducing bacterial resistance, the level I Trauma Intensive Care Unit (TICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban employs stewardship and an antimicrobial policy based on surveillance. This study was undertaken with three aims: (i) to describe the spectrum and sensitivities of nosocomial pathogens in a level I TICU; (ii) to ascertain, based on surveillance data, how frequently initial empiric choice of antimicrobials was correct; and (iii) to determine how frequently ultrabroad-spectrum antimicrobials were prescribed and were actually necessary. METHODS: Over a 12-month period, all critically injured patients who underwent mechanical ventilation in the TICU were identified from a prospectively gathered database. Information regarding every specimen submitted to the National Health Laboratory Services (NHLS) situated at IALCH was extracted from the laboratory computer database. For each patient, bacterial isolates and antimicrobial susceptibility were identified using standard laboratory techniques. Empiric prescriptions for presumed nosocomial sepsis were identified from the hospital's computerised patient record system and compared with culture results. Acinetobacter species were regarded as colonisers and treatment not offered unless this was the sole isolate in the presence of signs of severe sepsis. Results. Of 227 patients, 106 (46.6%) had 136 culture-positive isolates with a total of 323 pathogens (201 Gram-negative, 119 Gram-positive, 3 Candida albicans). There were 19 species of Gram-negative pathogens, of which 56% comprised Enterobacteriaceae. Extended spectrum beta-lactamase (ESBL) production was found in 6/31 (19%) Escherichia coli coli and 6/24 (25%) Klebsiella isolates. Staphyloccocal species accounted for 60% of the Gram-positive isolates, of which 18 were methicillin-resistant Staphylococcus aureus (MRSA). All Candida isolates were sensitive to fluconazole. One hundred and one empiric and 14 directed prescriptions were issued. Despite positive cultures, antimicrobials were not prescribed for 21 patients who had no evidence of sepsis. Excluding multidrug-resistant Acinetobacter isolates, there were 87 (93.5%) appropriate and 6 (6.5%) incorrect prescriptions. Ultrabroad-spectrum combination therapy (U-bSCT) was employed for 11 patients but was necessary in only 2. CONCLUSIONS: When combined with regular bacterial surveillance, antimicrobial stewardship allows accurate empiric antimicrobial prescription with minimal need for ultrabroad-spectrum combination therapy. This policy can potentially reduce the emergence of multidrug-resistant pathogens, precluding the need for broad-spectrum antimicrobials and the attendant problems of overuse.