Community-onset Escherichia coli infection resistant to expanded-spectrum cephalosporins in low-prevalence countries.

By global standards, the prevalence of community-onset expanded-spectrum-cephalosporin-resistant (ESC-R) Escherichia coli remains low in Australia and New Zealand. Of concern, our countries are in a unique position, with high extramural resistance pressure from close population and trade links to Asia-Pacific neighbors with high ESC-R E. coli rates. We aimed to characterize the risks and dynamics of community-onset ESC-R E. coli infection in our low-prevalence region. A case-control methodology was used. Patients with ESC-R E. coli or ESC-susceptible E. coli isolated from blood or urine were recruited at six geographically dispersed tertiary care hospitals in Australia and New Zealand. Epidemiological data were prospectively collected, and bacteria were retained for analysis. In total, 182 patients (91 cases and 91 controls) were recruited. Multivariate logistic regression identified risk factors for ESC-R among E. coli strains, including birth on the Indian subcontinent (odds ratio [OR]=11.13, 95% confidence interval [95% CI]=2.17 to 56.98, P=0.003), urinary tract infection in the past year (per-infection OR=1.430, 95% CI=1.13 to 1.82, P=0.003), travel to southeast Asia, China, the Indian subcontinent, Africa, and the Middle East (OR=3.089, 95% CI=1.29 to 7.38, P=0.011), prior exposure to trimethoprim with or without sulfamethoxazole and with or without an expanded-spectrum cephalosporin (OR=3.665, 95% CI=1.30 to 10.35, P=0.014), and health care exposure in the previous 6 months (OR=3.16, 95% CI=1.54 to 6.46, P=0.02). Among our ESC-R E. coli strains, the blaCTX-M ESBLs were dominant (83% of ESC-R E. coli strains), and the worldwide pandemic ST-131 clone was frequent (45% of ESC-R E. coli strains). In our low-prevalence setting, ESC-R among community-onset E. coli strains may be associated with both "export" from health care facilities into the community and direct "import" into the community from high-prevalence regions.

Age-related differences in SARS-CoV-2 testing in the Northern Region of New Zealand.

AIM: There is concern the low incidence of coronavirus disease 2019 (COVID-19) in children reflects under-testing in this population. This study sought to describe the age-distribution of SARS-CoV-2 testing in the Northern Region of New Zealand. METHODS: A retrospective single-centre review of all SARS-CoV-2 tests performed at LabPLUS, Auckland City Hospital, between 12 February and 18 April 2020. RESULTS: A total of 22,333 tests were performed, with 313 (1.40%) positive results. The age-adjusted SARS-CoV-2 testing rate was three times higher in adults than in children. The overall proportion of positive tests was lower in children (0.86%) than adults (1.45%). However, within the paediatric population the proportion of tests positive differed significantly between those <10 years old (0.08%) and those 10-14 years old (2.6%). CONCLUSION: The lower proportion of tests positive in children <10 years of age suggests they are appropriately tested relative to their rates of disease. A large high school-associated cluster makes the higher proportion of tests positive in children 10-14 years old difficult to interpret. Older children may have a higher risk of infection and increasing testing in intermediate and high school aged children may be indicated.

Group B Streptococcus in surgical site and non-invasive bacterial infections worldwide: A systematic review and meta-analysis.

OBJECTIVES: The epidemiology of disease caused by group B Streptococcus (GBS; Streptococcus agalactiae) outside pregnancy and the neonatal period is poorly characterized. The aim of this study was to quantify the role of GBS as a cause of surgical site and non-invasive infections at all ages. METHODS: A systematic review (PROSPERO CRD42017068914) and meta-analysis of GBS as a proportion (%) of bacterial isolates from surgical site infection (SSI), skin/soft tissue infection (SSTI), urinary tract infection (UTI), and respiratory tract infection (RTI) was conducted. RESULTS: Seventy-four studies and data sources were included, covering 67 countries. In orthopaedic surgery, GBS accounted for 0.37% (95% confidence interval (CI) 0.08-1.68%), 0.87% (95% CI 0.33-2.28%), and 1.46% (95% CI 0.49-4.29%) of superficial, deep, and organ/space SSI, respectively. GBS played a more significant role as a cause of post-caesarean section SSI, detected in 2.92% (95% CI 1.51-5.55%), 1.93% (95% CI 0.97-3.81%), and 9.69% (95% CI 6.72-13.8%) of superficial, deep, and organ/space SSI. Of the SSTI isolates, 1.89% (95% CI 1.16-3.05%) were GBS. The prevalence of GBS in community and hospital UTI isolates was 1.61% (1.13-2.30%) and 0.73% (0.43-1.23%), respectively. GBS was uncommonly associated with RTI, accounting for 0.35% (95% CI 0.19-0.63%) of community and 0.27% (95% CI 0.15-0.48%) of hospital RTI isolates. CONCLUSIONS: GBS is implicated in a small proportion of surgical site and non-invasive infections, but a substantial proportion of invasive SSI post-caesarean section.

Inappropriate prescribing of antibiotics following discharge after major surgery: an area for improvement.

AIM: This study aims to determine the indications for antibiotic use in patients discharged following major surgery at Auckland City Hospital (ACH); to determine if the indications were appropriate and to identify opportunities where antimicrobial stewardship interventions would be beneficial. METHODS: This was a retrospective study of adult patients who were dispensed an antibiotic within the first two days of discharge after major surgery at ACH between 1 January 2013 and 31 December 2013. The indication for antibiotic use was determined and subsequently classified as either 'appropriate', 'not assessable' or 'inappropriate'. RESULTS: Among the 378 patients analysed, an indication for antibiotic use was not documented in 52 patients (13.8%). Antibiotics were prescribed for an established infection in 172 patients (45.5%), as empiric therapy in 100 patients (26.4%), and as prolonged surgical antimicrobial prophylaxis in 41 patients (10.8%). Overall, nearly half of the antibiotic courses dispensed (48.7%) were either 'inappropriate' or the indication was 'not assessable'. CONCLUSIONS: This study demonstrates that a significant proportion of antibiotics prescribed in patients discharged following surgery are inappropriate and there is need for enhanced antimicrobial stewardship in this area.

Sequence type 131 fimH30 and fimH41 subclones amongst Escherichia coli isolates in Australia and New Zealand.

The clonal composition of Escherichia coli causing extra-intestinal infections includes ST131 and other common uropathogenic clones. Drivers for the spread of these clones and risks for their acquisition have been difficult to define. In this study, molecular epidemiology was combined with clinical data from 182 patients enrolled in a case-control study of community-onset expanded-spectrum cephalosporin-resistant E. coli (ESC-R-EC) in Australia and New Zealand. Genetic analysis included antimicrobial resistance mechanisms, clonality by DiversiLab (rep-PCR) and multilocus sequence typing (MLST), and subtyping of ST131 by identification of polymorphisms in the fimH gene. The clonal composition of expanded-spectrum cephalosporin-susceptible E. coli and ESC-R-EC isolates differed, with six MLST clusters amongst susceptible isolates (median 7 isolates/cluster) and three clusters amongst resistant isolates, including 40 (45%) ST131 isolates. Population estimates indicate that ST131 comprises 8% of all E. coli within our population; the fluoroquinolone-susceptible H41 subclone comprised 4.5% and the H30 subclone comprised 3.5%. The H30 subclone comprised 39% of all ESC-R-EC and 41% of all fluoroquinolone-resistant E. coli within our population. Patients with ST131 were also more likely than those with non-ST131 isolates to present with an upper than lower urinary tract infection (RR=1.8, 95% CI 1.01-3.1). ST131 and the H30 subclone were predominant amongst ESC-R-EC but were infrequent amongst susceptible isolates where the H41 subclone was more prevalent. Within our population, the proportional contribution of ST131 to fluoroquinolone resistance is comparable with that of other regions. In contrast, the overall burden of ST131 is low by global standards.

Predictors of hospital surface contamination with Extended-spectrum ß-lactamase-producing Escherichia coli and Klebsiella pneumoniae: patient and organism factors.

BACKGROUND: The role of the hospital environment in transmission of ESBL-Klebsiella pneumoniae (ESBL-KP) and ESBL-Escherichia coli (ESBL-EC) is poorly defined. Recent data however suggest that in the hospital setting, ESBL-KP is more transmissible than ESBL-EC. We sought therefore to measure the difference in hospital contamination rates between the two species and to identify key risk factors for contamination of the hospital environment with these organisms. METHODS: We systematically sampled 8 surfaces in the rooms and bathrooms of adult patients colonized or infected with ESBL-EC or ESBL-KP throughout their hospital stay. Data were collected on factors potentially affecting contamination rates. Environmental contamination was defined as recovery of an ESBL-producing organism matching the source patient's isolate. Multivariate logistic regression analysis was performed at the level of the patient visit using generalized estimating equations to identify independent predictors of environmental contamination. RESULTS: 24 patients (11 with ESBL-KP, 11 ESBL-EC and 2 with both organisms) had 1104 swabs collected during 138 visits. The overall contamination rate was 3.4% (38/1104) and was significantly higher for ESBL-KP than ESBL-EC (5.4% versus 0.4%; p < 0.0001). After multivariate analysis, environmental contamination was found to be negatively associated with carbapenem exposure (OR 0.06 [95% CI 0.01-0.61]; p = 0.017) and positively associated with the presence of an indwelling urinary catheter (OR 6.12 [95% CI 1.23-30.37]; p = 0.027) and ESBL-KP in the source patient (OR 26.23 [95% CI 2.70-254.67]; p = 0.005). CONCLUSIONS: Contamination of the hospital environment with ESBL-producing Enterobacteriaceae (ESBL-E) is inversely associated with carbapenem exposure. Predictors of hospital contamination with ESBL-E include: indwelling urinary catheters and ESBL-KP. Rooms of patients with ESBL-KP have substantially higher contamination rates than those with ESBL-EC. This finding may help explain the apparently higher transmissibility of ESBL-KP in the hospital setting.

Severe Clostridium difficile infection in New Zealand associated with an emerging strain, PCR-ribotype 244.

AIM: To compare disease severity and clinical outcome of Clostridium difficile infection (CDI) due to PCR-ribotype (RT) 244 with CDI due to other strains present in Auckland. METHOD: A retrospective, case-control study was conducted. Ten cases with CDI due to RT 244 were compared with 20 controls infected with other C. difficile strains. RT 244 isolates were further analysed for antimicrobial susceptibility, binary toxin genes and mutations in the tcdC gene. RESULTS: Cases were significantly more likely to have severe disease than controls (OR 9.33; p=0.015). 50% of cases had community-associated CDI compared with 15% of controls (p=0.078). All RT 244 isolates produced binary toxin and had a single-base pair deletion in tcdC at position 117. CONCLUSION: C. difficile RT 244 is a newly recognised strain in New Zealand. It shares several features that characterise RT 027. Given its propensity to cause severe community-associated disease, a heightened awareness of this strain is needed to ensure early testing in patients admitted from the community with identified risk factors for CDI.

Impact of pediatric critical illness and injury on families: a systematic literature review.

OBJECTIVE: We sought to inform decision-making for children and families by describing what is known and remains unknown about the impact of childhood critical illness and injury on families. This report also was designed as a tool for research planning and design so that meaningful studies are performed and duplication is avoided. DESIGN: After a national scholarship competition and the identification of 3 medical student summer scholars, a literature search was conducted by using the National Library of Medicine and a PubMed keyword search system at the National Institutes of Health. RESULTS: A total of 115 reports were reviewed and assigned to the 5 following categories characterizing the impact of pediatric critical illness/injury on families: stressors, needs, specific domains (psychological, physical, social), coping, and interventions. The reports reviewed indicate that pediatric critical illness and injury is stressful for the entire family. The effects on parents, siblings, and marital cohesion were variably described. Needs of family members (eg, rest, nutrition, communication) were identified as being unmet in many studies. Permanent impact on siblings and marital relationships has been considered detrimental, but these conclusions are not adequately quantified in presently available studies. Reviewed reports minimally investigated cultural diversity, effects on fathers versus mothers, siblings, socioeconomic status, and financial burden. Studies were often anecdotal and included small sample sizes. Methodologic limitations were numerous and varied and seriously narrowed the significance of the studies we reviewed. The reports that we evaluated were largely limited to those of English-speaking families, white people, and married mothers. CONCLUSIONS: Future research should use more rigorous methods in the measurement of impact of childhood critical illness and injury on families. Families of critically ill and injured children would benefit from the practitioners of pediatric critical care acquiring enhanced knowledge and sensitivity about family communication and dynamics.