Infection prevention and control policy implementation for CPE: a cross-sectional national survey of healthcare workers reveals knowledge gaps and suboptimal practices.

BACKGROUND: In 2017, Ireland pioneered a unique response to the worsening epidemiology of carbapenemase-producing Enterobacterales (CPE), declaring a national public health emergency. Subsequently, CPE mitigation guidelines and policies were implemented in acute hospitals, focused on patient screening and outbreak management, often by healthcare workers (HCWs) with limited background in infection prevention and control (IPC). CPE risks from sinks and drains remain inadequately controlled. AIMS: To compare CPE awareness, perceptions of the role of the environment in CPE transmission, and disposal practices of liquid waste from clinical handwashing sinks between IPC HCWs and non-IPC HCWs in Ireland. METHODS: Between December 2022 and March 2023, HCWs employed in acute hospitals in Ireland between 2017 and 2022 were invited to participate anonymously in a 30-question digital survey. FINDINGS: Responses (N=283) were received across several clinical disciplines. In total, 21.6% of respondents were working or had previously worked in IPC roles, 84.1% of whom reported no IPC-related learning needs. In comparison with non-IPC HCWs, more IPC HCWs perceived a risk of pathogen transmission from clean water plumbing (68.9% vs 39.2%; P<0.001) and waste/drainage plumbing (81.2% vs 43.7%; P<0.001). Among nursing and medical staff, only 5.6% of IPC HCWs used clinical handwashing sinks for disposal of liquid waste, compared with 60% of non-IPC HCWs (P<0.001). In comparison with non-IPC HCWs, a greater proportion of IPC HCWs reported that they had witnessed colleagues routinely discarding liquid waste (including nutritional products, antimicrobials and patient body fluids) via clinical handwashing sinks (88.9% vs 77.9%) CONCLUSIONS: Although there is general awareness of the role of the built environment in pathogen transmission, including CPE, familiarity with sink/water-related transmission is greater among IPC HCWs. There may be opportunities to improve disposal practices for liquid waste through education targeting non-IPC HCWs.

Nutritional drinks and enteral feeds promote the growth of carbapenemase-producing Enterobacterales in conditions that simulate disposal in hospital sinks.

BACKGROUND: Studies have shown that nutritional products are discarded via handwash sinks by healthcare workers, and this practice may promote bacterial growth, including growth of pathogens such as carbapenemase-producing Enterobacterales (CPE). Outbreaks and acquisition of CPE in nosocomial settings are associated with negative outcomes for patients and hospitals. OBJECTIVES: To investigate the potential growth-promoting effect of nutritional support drinks (NSDs) and enteral tube-feed products (ETFPs) on CPE. METHODS: Six different CPE strains were grown in five different diluted NSDs, five different diluted ETFPs, Mueller-Hinton broth (MHB) and M9 minimal salts media to simulate discarding a small volume of nutritional product in a u-bend, already containing liquid. CPE were enumerated at 0 h, 6 h and 24 h, and compared using two-way analysis of variance and Dunett test, with confidence levels at 95%. Spearman's r was used to measure the strength of correlation between component concentrations in nutritional products and CPE growth. RESULTS: All NSDs and ETFPs promoted CPE growth that exceeded both M9 (negative growth control) and MHB (positive growth control). In several cases, growth in NSDs/ETFPs was significantly greater compared with growth in MHB. CONCLUSION: Nutritional products support CPE growth under in-vitro conditions. The propensity of CPE to survive in drain pipework suggests that inappropriate product disposal may further nourish established CPE in these environmental reservoirs. The growth observed in diluted NSDs and ETFPs shows that modifiable practices should be optimized to mitigate the potential risk of CPE transmission from these reservoirs.

Genotyping of long term persistent Staphylococcus aureus in bovine subclinical mastitis.

Bovine mastitis affects dairy cattle worldwide and Staphylococcus aureus is one of the most common microorganisms involved in subclinical and chronic disease. Superantigens, such as enterotoxins contribute to S. aureus persistence and pathogenicity in this disease. Subclinical and chronic mastitis cases were diagnosed and S. aureus isolates from sub-clinical cases were investigated for carriage of virulence and antibiotic resistance genes that may contribute to long-term carriage and infection. Over a 12-month period, 116 S. aureus strains were recovered from 68 cows with subclinical mastitis. Classical enterotoxin genes (sea-see) were detected in 24.1% of isolates, and pvl and tsst-1 were identified in 3.4% and 46.6% the isolates, respectively. 18.1% that were persistent isolates were identified and characterized by pulsed field gel electrophoresis (PFGE), MLST, spa typing. Four isolates were methicillin-resistant S. aureus (MRSA) and belonged to SCCmec type I. Molecular typing showed that the agrI group was the most frequent, and a rare isolate was positive for both agrI and agrIII groups. Molecular characterization revealed the persistence of the spa type t10856 (ST133, clonal complex CC133, agr I), in a single animal for nine months and the persistence t605 (ST126, CC126) colonizing four animals for four months. These strains have been described recently in other herds in the same region, indicating their transmissibility and clonal expansion. We conclude that animals with subclinical mastitis are an important and somewhat overlooked reservoir for transmission within and between herds, and may carry virulence and antibiotic resistance genes contributing to persistent colonization, hinder the control of mastitis and may cause risks to the public health.

Reduced pro-inflammatory responses to Staphylococcus aureus bloodstream infection and low prevalence of enterotoxin genes in isolates from patients on haemodialysis.

Patients with end-stage renal failure undergo regular haemodialysis (HD) and often develop episodes of Staphylococcus aureus bloodstream infection (BSI), which can re-occur. However, clinically, patients on HD, with S. aureus BSI, respond well to treatment, rarely developing overt signs of sepsis. We investigated the contributions of bacterial virulence and cytokine responses to the clinical course of S. aureus BSI in HD and non-HD patients. Seventy patients were recruited, including 27 (38.6 %) patients on HD. Isolates were spa-typed and virulence and antimicrobial resistance gene carriage was investigated using DNA microarray analysis. Four inflammatory cytokines, IL-6, RANTES, GROγ and leptin, were measured in patient plasma on the day of diagnosis and after 7 days. There was no significant difference in the prevalence of genotypes or antimicrobial resistance genes in S. aureus isolates from HD compared to non-HD patients. The enterotoxin gene cluster (containing staphylococcal enterotoxins seg, sei, sem, sen, seo and seu) was significantly less prevalent among BSI isolates from HD patients compared to non-HD patients. Comparing inflammatory cytokine response to S. aureus BSI in HD patients to non-HD patients, IL-6 and GROγ were significantly lower (p = 0.021 and p = 0.001, respectively) in HD patients compared to other patients on the day of diagnosis and RANTES levels were significantly lower (p = 0.025) in HD patients on day 7 following diagnosis. Lowered cytokine responses in HD patients and a reduced potential for super-antigen production by infecting isolates may partly explain the favourable clinical responses to episodes of S. aureus BSI in HD patients that we noted clinically.

Novel class of Bi(iii) hydroxamato complexes: synthesis, urease inhibitory activity and activity against H. pylori.

Reaction of Bi(NO3)3 with benzohydroxamic acid (Bha) and salicylhydroxamic acid (Sha) gives the novel Bi(iii) complexes [Bi2(Bha-1H)2(µ-Bha-1H)2(η(2)-NO3)2] () and [Bi6(CH3OH)2(η(1)-NO3)2(η(2)-NO3)(OH2)2(Sha-1H)12](NO3)2 (). X-ray crystal structure of reveals two hydroxamato coordination modes; bidentate bridging (O, O') and bidentate non-bridging (O, O') and of reveals one coordination mode; bidentate bridging (O, O'). , specifically designed to and demonstrated to inhibit the activity of urease, exhibits excellent antibacterial activity against three strains of Helicobacter pylori with MIC ≥ 16 µg mL(-1).

Effect of essential oils of Syzygium aromaticum and Cinnamomum zeylanicum and their major components on biofilm production in Staphylococcus aureus strains isolated from milk of cows with mastitis.

Bovine mastitis is an inflammation of the mammary glands of cows and causes significant economic losses in dairy cattle. Staphylococcus aureus is one of the microorganisms most commonly isolated. Novel agents are required in agricultural industries to prevent the development of mastitis. The production of biofilm by Staph. aureus facilitates the adhesion of bacteria to solid surfaces and contributes to the transmission and maintenance of these bacteria. The effect of the essential oils of Syzygium aromaticum (clove; EOSA) and Cinnamomum zeylanicum (cinnamon; EOCZ) and their major components, eugenol and cinnamaldehyde, on Staph. aureus biofilm formation on different surfaces was investigated. The results showed a significant inhibition of biofilm production by EOSA on polystyrene and stainless steel surfaces (69.4 and 63.6%, respectively). However, its major component, eugenol, was less effective on polystyrene and stainless steel (52.8 and 19.6%, respectively). Both EOCZ and its major component, cinnamaldehyde, significantly reduced biofilm formation on polystyrene (74.7 and 69.6%, respectively) and on stainless steel surfaces (45.3 and 44.9%, respectively). These findings suggest that EOSA, EOCZ, and cinnamaldehyde may be considered for applications such as sanitization in the food industry.

Air and surface contamination patterns of meticillin-resistant Staphylococcus aureus on eight acute hospital wards.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) can be recovered from hospital air and from environmental surfaces. This poses a potential risk of transmission to patients. AIM: To investigate associations between MRSA isolates recovered from air and environmental surfaces with those from patients when undertaking extensive patient and environmental sampling. METHODS: This was a prospective observational study of patients and their environment in eight wards of a 700-bed tertiary care hospital during 2010 and 2011. Sampling of patients, air and surfaces was carried out on all ward bays, with more extended environmental sampling in ward high-dependency bays and at particular times of the day. The genetic relatedness of isolates was determined by DNA microarray profiling and spa typing. FINDINGS: MRSA was recovered from 30/706 (4.3%) patients and from 19/132 (14.4%) air samples. On 9/132 (6.8%) occasions both patient and air samples yielded MRSA. In 32 high-dependency bays, MRSA was recovered from 12/161 (7.4%) patients, 8/32 (25%) air samples, and 21/644 (3.3%) environmental surface samples. On 10/132 (7.6%) occasions, MRSA was isolated from air in the absence of MRSA-positive patients. Patient demographic data combined with spa typing and DNA microarray profiling revealed four likely transmission clusters, where patient and environmental isolates were deemed to be very closely related. CONCLUSION: Air sampling yielded MRSA on frequent occasions, especially in high-dependency bays. Environmental and air sampling combined with patient demographic data, spa typing and DNA microarray profiling indicated the presence of clusters that were not otherwise apparent.

Transmission of endemic ST22-MRSA-IV on four acute hospital wards investigated using a combination of spa, dru and pulsed-field gel electrophoresis typing.

The transmission of meticillin-resistant Staphylococcus aureus (MRSA) between individual patients is difficult to track in institutions where MRSA is endemic. We investigated the transmission of MRSA where ST22-MRSA-IV is endemic on four wards using demographic data, patient and environmental screening, and molecular typing of isolates. A total of 939 patients were screened, 636 within 72 h of admission (on admission) and 303 >72 h after admission, and 1,252 environmental samples were obtained. Isolates were typed by spa, dru and pulsed-field gel electrophoresis (PFGE) typing. A composite dendrogram generated from the three sets of typing data was used to divide isolates into 'dendrogram groups' (DGs). Ten percent of patients (92/939) were MRSA-positive; 7 % (44/636) on admission and 16 % (48/303) >72 h after admission (p = 0.0007). MRSA was recovered from 5 % of environmental specimens (65/1,252). Most isolates from patients (97 %, 85/88) and the environment (97 %, 63/65) exhibited the ST22-MRSA-IV genotype. Four DGs (DG1, DG4, DG16 and DG17) accounted for 58 % of ST22-MRSA-IV isolates from patients. Epidemiological evidence suggested cross-transmission among 44/92 patients (48 %) but molecular typing confirmed probable cross-transmission in only 11 instances (13 %, 11/88), with the majority of cross-transmission (64 %; 7/11) occurring on one ward. In the setting of highly clonal endemic MRSA, the combination of local epidemiology, PFGE, spa and dru typing provided valuable insights into MRSA transmission.

The revolving door between hospital and community: extended-spectrum beta-lactamase-producing Escherichia coli in Dublin.

BACKGROUND: Escherichia coli that produce extended-spectrum beta-lactamases (ESBLs) are an increasing cause of healthcare-associated infection, and community healthcare facilities may be a reservoir for important epidemic clones. AIM: To characterize retrospectively and investigate the epidemiology of ESBL-producing E. coli collected in a Dublin hospital, during 2009 and 2010, and to investigate the dissemination of specific clones within hospital and community healthcare facilities. METHODS: Pulsed-field gel electrophoresis (PFGE) was used to determine the genetic relatedness of 100 ESBL-producing E. coli isolates. Phylogenetic groups were determined and the O25b-ST131 clone identified in the collection. The genetic data were correlated with antimicrobial susceptibility, clinical and demographic data to explore the epidemiology of specific clones. FINDINGS: Phylogenetic groups B2 (62%) and D (18%) were the most common and were associated with non-urinary isolates (P<0.0001 by Fisher's exact test). PFGE revealed 12 clusters (≥ 80% similarity), the largest of which clustered with the epidemic UK strain A. Residents of long-term care facilities (LTCFs) in the community exclusively carried the O25b-ST131 clone and phylogenetic groups B2 and D. CONCLUSIONS: E. coli O25b-ST131 is largely responsible for ESBL-producing E. coli in LTCFs in Dublin. The distribution of ESBL-producing E. coli in our hospital and community highlights a 'revolving door' through which these resistant bacteria spread and disseminate.

Evaluation of vaporized hydrogen peroxide, Citrox and pH neutral Ecasol for decontamination of an enclosed area: a pilot study.

Hydrogen peroxide, Ecasol and Citrox aerosols were each tested for their ability to kill a range of nosocomial pathogens. Hydrogen peroxide had the broadest microbicidal activity but operational issues limit its use. Ecasol was effective against all micro-organisms, except Clostridium difficile, while Citrox aerosols were not effective against Gram-negative bacilli.

When are the hands of healthcare workers positive for methicillin-resistant Staphylococcus aureus?

Hand hygiene is a key component in reducing infection. There are few reports on the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) on healthcare workers' (HCWs') hands. The aim of this study was to establish whether HCWs' fingertips were contaminated with MRSA in a clinical hospital setting. The study was conducted in an acute tertiary referral hospital on four MRSA wards that were part of a larger research study on MRSA epidemiology and four other wards not included in the study. The fingertips from all categories of 523 HCWs were sampled on 822 occasions by the imprinting of fingertips on MRSA chromogenic agar plates. The type of hand hygiene agent used, if any, and the immediate prior activity of the HCW were recorded. Overall, 38/822 (5%) fingertips from 523 HCWs were MRSA-positive; 12/194 (6%) after clinical contact, 10/138 (10%) after contact with the patient's environment and 15/346 (4%) after no specific contact. MRSA was recovered on 2/61 (3%) occasions after use of alcohol hand rub, 2/35 (6%) after 4% chlorhexidine detergent, 7/210 (3%) hand washing with soap and water, and 27/493 (5%) when no hand hygiene had been performed. MRSA was recovered from HCWs on seven of the eight wards. MRSA was more frequently present on fingertips on the four non-study wards vs the four MRSA study wards [18/250 (7%), 3/201 (1%), respectively; P