RESUMO
We report 5 cases of vascular Q fever complicated by polymicrobial superinfection in patients who had no risk factors for acute Q fever. Q fever was diagnosed by serologic and molecular assays for Coxiella burnetii. We confirmed additional infections using conventional graft cultures.
Assuntos
Coinfecção , Coxiella burnetii , Febre Q , França , Humanos , Fatores de RiscoRESUMO
OBJECTIVES: The aim was to compare the antimicrobial efficacy of four different grafts: a standard graft (Intergard, IG), an IG graft soaked in rifampicin (IGrif), a silver impregnated graft (Intergard Silver, IGS), and a silver + triclosan impregnated graft (Intergard Synergy, IGSy). METHODS: This was a seven day in vitro study. The IG, IGrif, IGS, and IGSy grafts were each contaminated separately with the following microorganisms: Staphylococcus epidermidis, Methicillin resistant Staphylococcus aureus (MRSA), Escherichia coli, and Candida albicans from both clinical and American Type Culture Collection (ATCC) origins. The in vitro antimicrobial efficacy was evaluated by time to kill assays at T0, T24h, T48h, T72h, and T168h. Bactericidal activity was defined as >3 log10 reduction factor (logRF). Additionally, Rifampicin, triclosan and silver resistance development were screened. RESULTS: As anticipated for the non-antimicrobial IG, all microorganism strains proliferated. The IGSy and the IGS showed a seven day bactericidal efficacy (>3 logRF) for all tested microorganisms. This efficacy was confirmed at all time points for IGSy only, demonstrating faster bactericidal efficacy than IGS. The IGrif demonstrated a seven day bactericidal efficacy against the ATCC MRSA only, while showing no activity against C. albicans and ATCC E. coli. Regarding ATCC S. epidermidis, clinical MRSA and clinical E. coli, IGrif, although bactericidal at earlier time points, lost its antimicrobial efficacy at seven days leading to the emergence of rifampicin resistant mutants in four of six, two of six, and two of six assays, respectively. Mutant strains were also detected in ATCC MRSA in one of six assays. No triclosan or silver resistance has emerged at T7days. CONCLUSION: For all microorganisms tested, the Synergy graft combining silver with triclosan demonstrated a more sustainable and efficient seven day antimicrobial activity than the rifampicin soaked graft. The emergence of rifampicin resistant mutants suggests preference for a Synergy graft over a graft soaked in rifampicin, to prevent or treat an infection when a biological solution is not feasible.
Assuntos
Antibacterianos/farmacologia , Antifúngicos/farmacologia , Bactérias/efeitos dos fármacos , Prótese Vascular , Candida albicans/efeitos dos fármacos , Materiais Revestidos Biocompatíveis , Rifampina/farmacologia , Compostos de Prata/farmacologia , Triclosan/farmacologia , Bactérias/genética , Bactérias/crescimento & desenvolvimento , Candida albicans/crescimento & desenvolvimento , Farmacorresistência Bacteriana , Teste de Materiais , Testes de Sensibilidade Microbiana , Desenho de Prótese , Fatores de TempoRESUMO
BACKGROUND: Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU. METHODS: Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy. RESULTS: Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting. CONCLUSION: Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
Assuntos
Portador Sadio/diagnóstico , Fezes/microbiologia , Programas de Rastreamento/métodos , beta-Lactamases/análise , Adulto , Portador Sadio/fisiopatologia , Infecção Hospitalar/prevenção & controle , Enterobacteriaceae/metabolismo , Enterobacteriaceae/patogenicidade , Infecções por Enterobacteriaceae/diagnóstico , Infecções por Enterobacteriaceae/fisiopatologia , Infecções por Enterobacteriaceae/prevenção & controle , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Programas de Rastreamento/tendências , Testes de Sensibilidade Microbiana/métodos , beta-Lactamases/efeitos adversos , beta-Lactamases/metabolismoRESUMO
Diagnosis of prosthetic vascular graft infection (PVGI) is a clinical challenge requiring accurate diagnostic methods for their optimal management. A 65-year-old patient with suspected PVGI was explored by fluorodeoxyglucose positron emission tomography combined with computed tomography ((18)F-FDG PET-CT) for pretreatment staging. Standard imaging was unrevealing but PET images showed multiple foci with increased uptake suggesting prosthetic infection. While routine results from the diagnostic laboratory were negative, prosthesis sonication before standard culture revealed the same bacterium as a culture of preoperative lymphocele aspiration. (18)F-FDG PET-CT and preliminary sonication of the prosthetic graft could be very helpful in the diagnosis of PVGI especially for highlighting biofilm bacteria.
Assuntos
Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Fluordesoxiglucose F18 , Tomografia por Emissão de Pósitrons , Infecções Relacionadas à Prótese/diagnóstico por imagem , Compostos Radiofarmacêuticos , Tomografia Computadorizada por Raios X , Idoso , Bactérias/crescimento & desenvolvimento , Bactérias/isolamento & purificação , Biofilmes , Implante de Prótese Vascular/instrumentação , Remoção de Dispositivo , Humanos , Contagem de Leucócitos , Masculino , Imagem Multimodal , Valor Preditivo dos Testes , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/cirurgia , Reoperação , Veia Safena/transplante , Sonicação , Resultado do TratamentoRESUMO
Antimicrobial resistance (AMR) is a global public health threat. Quality data are needed to address the rise of multidrug-resistant clones, particularly in sub-Saharan Africa. In this study, we analysed the prevalence, antimicrobial resistance profile, and presence of genes encoding extended-spectrum ß-lactamase-producing Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp) in environmental samples from Ouagadougou, Burkina Faso. Of 264 samples collected, 95 (36%) and 74 (28%) contained ESBL-Kp and ESBL-Ec, respectively. ESBL-Kp was more prevalent in runoff water and in treated and untreated wastewater, while ESBL-Ec was more prevalent in manure. Interestingly, wastewater treatment did not significantly reduce the recovery of ESBL bacteria. As expected, resistance to third- and fourth-generation cephalosporins was predominant, and rare for second generation cefoxitin. Interestingly, all the isolates from treated wastewater were susceptible to ampicillin and piperacillin, while all the other clones were resistant to these antibiotics. Regarding the ESBL-encoding genes, the blaCTX-M family was the most abundant, with the blaCTX-M1 subfamily being the most prevalent. Carriage of combinations of ESBL genes was common, with the majority of the isolates harbouring 2-4 different genes. This study highlights the need for active surveillance to manage the risk of exposure to ESBL bacteria in Burkina Faso.
RESUMO
Objective: Many experimental studies have been conducted to evaluate vascular and endovascular graft infections (VGEIs) and infectability in order to elaborate strategies to prevent or to treat their occurrence. A systematic literature search was conducted to collect and summarise key features of infection and infectability assessment techniques in VGEI experimental models. Methods: The literature search was conducted using the Medline and Cochrane databases, with no limit on the date of publication, until 10 August 2021. Ex vivo, in vitro, and in vivo animal studies on VGEIs, published in English or French, were selected. Cross references retrieved from selected articles on PubMed database were also included in the search. Data were collected on the techniques and the protocols performed for vascular graft infection and infectability assessment. Results: A total of 243 studies were included in the review: 55 in vitro studies, 169 animal studies, 17 combining the two models, and two ex vivo studies. Many experimental techniques were performed, with a lot of protocol discrepancies. The main experiments conducted were bacterial culture, with (n = 82 studies) or without sonication (n = 120), histopathology (n = 69), scanning electron microscopy (n = 36), and graft diffusion tests (n = 28). These techniques were used to answer different research questions corresponding to different graft infection steps, such as microbial adhesion and/or viability, biofilm biomass or organisation, human cell reaction, or antimicrobial activity. Conclusion: Many experimental tools are available to study VGEIs, but to improve their reproducibility and scientific reliability research protocols must be standardised and include sonication of grafts before microbiological culture. Moreover, the key role of the biofilm in VGEI physiopathology must be taken into account in future studies.
RESUMO
Background: Catheter-related bloodstream infections (CRBIs) remain a major cause of mortality in haemodialysis (HD) patients with central venous catheters (CVCs), especially because of the non-specific symptomatology and the delay in microbiological diagnosis with possible use of non-optimal empiric antibiotics. Moreover, empiric broad-spectrum antibiotics increase antibiotic resistance development. This study aims to evaluate the diagnostic performance of real-time polymerase chain reaction (rt-PCR) in suspected HD CRBIs compared with blood cultures. Methods: A blood sample for rt-PCR was collected simultaneously with each pair of blood cultures for suspected HD CRBI. The rt-PCR was performed on the whole blood, without any enrichment stage and with specific DNA primers: 16S (universal bacterial), Staphylococcus spp., Staphylococcus aureus and mecA. Each successive patient with a suspected HD CRBI in the HD centre of Bordeaux University Hospital was included. Performance tests were used to compare the result obtained in each rt-PCR assay with its corresponding routine blood culture. Results: Eighty-four paired samples were collected and compared for 40 suspected HD CRBI events in 37 patients. Among these, 13 (32.5%) were diagnosed as HD CRBI. All rt-PCRs except mecA (insufficient number of positive samples) showed high diagnostic performances within 3.5 h: 16S (sensitivity 100%, specificity 78%), Staphylococcus spp. (sensitivity 100%, specificity 97%), S. aureus (sensitivity 100%, specificity 99%). Based on the rt-PCR results, antibiotics could be more appropriately targeted, thus cutting anti-cocci Gram-positive therapy from 77% to 29%. Conclusions: The performance of rt-PCR in suspected HD CRBI events showed fast and high diagnostic accuracy. Its use would improve HD CRBI management with an antibiotic consumption decrease.
RESUMO
Hospital wastewater is a recognized reservoir for resistant Gram-negative bacteria. This study aimed to screen for carbapenemase-producing Escherichia coli and Klebsiella pneumoniae and their resistance determinants in two hospital effluents of Ouagadougou. Carbapenem-resistant E. coli and K. pneumoniae were selectively isolated from wastewater collected from two public hospitals in Ouagadougou, Burkina Faso. Bacterial species were identified via MALDI-TOF mass spectrometry. Carbapenemase production was studied phenotypically using antibiotic susceptibility testing via the disk diffusion method. The presence of carbapenemases was further characterized by PCR. A total of 14 E. coli (13.59%) and 19 K. pneumoniae (17.92%) carbapenemase-producing isolates were identified with different distributions. They were, respectively, blaNDM (71.43%), blaVIM (42.86%), blaIMP (28.57%), blaKPC (14.29%), blaOXA-48 (14.29%); and blaKPC (68.42%), blaNDM (68.42%), blaIMP (10.53%), blaVIM (10.53%), and blaOXA-48 (5.26%). In addition, eight (57.14%) E. coli and eleven (57.89%) K. pneumoniae isolates exhibited more than one carbapenemase, KPC and NDM being the most prevalent combination. Our results highlight the presence of clinically relevant carbapenemase-producing isolates in hospital effluents, suggesting their presence also in hospitals. Their spread into the environment via hospital effluents calls for intensive antimicrobial resistance (AMR) surveillance.
RESUMO
BACKGROUND: The worldwide dissemination of extended spectrum beta-lactamase producing Enterobacteriales (ESBL-E) is of major concern. Microbiota may play a role in the host resistance to colonization with ESBL-E, but the underlying mechanisms remain unknown. We aimed to compare the gut microbiota composition between ESBL-producing E. coli or K. pneumoniae carriers and ESBL-E non-carriers according to the bacterial species. RESULTS: Among 255 patients included, 11 (4,3%) were colonized with ESBL-producing E. coli and 6 (2,4%) with ESBL-producing K. pneumoniae, which were compared with age- and sex-matched ESBL-E non carriers. While no significant differences were found between ESBL-producing E. coli carriers and non-carriers, gut bacteriobiota α-diversity was decreased in ESBL-K. pneumoniae faecal carriers compared both with non-carriers (p = 0.05), and with ESBL-producing E. coli carriers. The presence of Sellimonas intestinalis was associated with the absence of ESBL-producing E. coli fecal carriage. Campylobacter ureolyticus, Campylobacter hominis, bacteria belonging to Clostridium cluster XI and Saccharomyces sp. were associated with the absence of ESBL-producing K. pneumoniae faecal carriage. CONCLUSIONS: The composition of the gut microbiota differs between ESBL-producing E. coli and K. pneumoniae faecal carriers suggesting that microbial species should be taken into account when investigating the role of gut microbiota in resistance to gut colonization with ESBL-E. TRIAL REGISTRATION NUMBER: NCT04131569, date of registration: October 18, 2019.
RESUMO
A carbapenem-resistant Klebsiella pneumoniae strain, Kp5196, was responsible for an uncomplicated cystitis in a patient living at home and without history of foreign travel. This isolate produced the metallocarbapenemase NDM-1 and was resistant to all antibiotics except tetracyclines and colistin. The K. pneumoniae strain belonged to sequence type ST15, and bla(NDM-1) was carried by a nontypeable conjugative plasmid. Two months later, a similar ST15 isolate, Kp5241, was present in the patient but was additionally colistin resistant.
Assuntos
Antibacterianos/farmacologia , Colistina/farmacologia , Klebsiella pneumoniae/efeitos dos fármacos , Klebsiella pneumoniae/enzimologia , Farmacorresistência Bacteriana Múltipla/genética , Humanos , Plasmídeos/genética , Tetraciclinas/farmacologia , beta-Lactamases/genéticaRESUMO
Background: Many experimental models have been developed to decipher the mechanisms of vascular graft and endograft infections (VGEIs), and to elaborate strategies to prevent or treat their occurrence. A systematic literature research was conducted to identify the most accurate models for studying VGEIs, depending on the research question. Methods: A narrative literature search was conducted using the MEDLINE and Cochrane databases, with no set limit on the date of publication, up to 10 August 2021. Ex vivo, in vitro, and in vivo animal studies on VGEIs, published in English or French, were selected. Cross references retrieved from selected articles on PubMed database were also included. Data on microorganisms and grafts studied, details of experimental models, and of graft implantation and removal in animal studies were collected. Results: A total of 243 studies were included in the review after reading the full length articles: 55 in vitro studies, 169 animal studies, 17 studies which used both in vitro and animal models, and two ex vivo studies. Many differences in model characteristics were seen. The main in vitro model was the incubation of a graft sample in a bacterial solution, used to study the first steps of infection. In animals, vascular large animal models (dogs and pigs) were the most commonly described but supplanted over time by extravascular and particularly subcutaneous mouse and rat models, which have been reported increasingly over the last few years. In animal models, antibiotic prophylaxis and therapy were rarely administered (27.4% and 19.9%, respectively), and vascular reconstruction after VGEIs even less frequently (9.8%). Conclusion: Despite protocol discrepancies, it was possible to dinstinguish three main experimental models (i.e., in vitro and in vivo vascular models, and extravascular models), which all remain of interest to study specific phases of VGEIs.
RESUMO
(1) Background: Three antimicrobial absorbable sutures have different triclosan (TS) loads, triclosan release kinetics and hydrolysis times. This in vitro study aims to analyse and compare their antimicrobial pharmacodynamics. (2) Methods: Time-kill assays were performed with eight triclosan-susceptible microorganisms common in surgical site infections (SSIs) and a segment of each TS. Microbial concentrations were measured at T0, T4, T8 and T24 h. Similar non-triclosan sutures (NTS) were used as controls. Microbial concentrations were plotted and analysed with panel analysis. They were predicted over time with a double-exponential model and four parameters fitted to each TS × microorganism combination. (3) Results: The microbial concentration was associated with the triclosan presence, timeslot and microorganism. It was not associated with the suture material. All combinations shared a common pattern with an early steep concentration reduction from baseline to 4-8 h, followed by a concentration up to a 24-h plateau in most cases with a mild concentration increase. (4) Conclusions: Microorganisms seem to be predominantly killed by contact or near-contact killing with the suture rather than the triclosan concentration in the culture medium. No significant in vitro antimicrobial pharmacodynamic difference between the three TS is identified. Triclosan can reduce the suture microbial colonisation and SSI risk.
RESUMO
During a two-month period (2017-2018), 336 urine samples positive for Escherichia coli were collected from Tunisian patients. Of the 336 samples, 266 were collected from community patients and 70 from hospital settings. In all, 15 ESBL producers were identified (8 and 7, respectively) and assigned to 13 pulsotypes, including four ESBL-producing E. coli (ESBL-E) with E1 and E2 profiles (2 isolates each) from community patients. The two strains E1 were identified as B2-ST131 subclade C2 and the two isolates E2, A-ST617. The four strains carrying both CTX-M-15 and CTX-M-27, exhibited the multireplicon IncFII/F1A/F1B with the same formula F31:A4:B1. Two isolates with patterns E3 and E4 (Dice coefficient, 78.7%) isolated from community and hospital settings of two geographic areas were assigned to the emerging ST131 C1-M27 subclade and contained the replicon F1:A-:B20. The remaining ESBL-E divided into different sequence types/associated CTX-M: 2 ST131-C2/CTX-M-15 and ST744/CTX-M-55, ST617/CTM-15, ST2973/CTX-M-55, ST6448/CTX-M-15, ST224/CTX-M-15, ST1431/CTX-M-15, and ST38/CTX-M-27, one isolate each. Our study reports for the first time the presence in the Tunisian community of two clones of E. coli, including the virulent clone ST131-C2 harboring both CTX-M-15 and CTX-M-27, and confirms the spread of the emergent clone ST131-C1-M-27, notably in community urinary tract infections.
RESUMO
Patients in hemodialysis on central venous catheter as vascular access are at risk of infections. Catheter-related bloodstream infection is one of the most serious catheter-complications in hemodialysis patients. Its clinical and microbiological diagnosis is challenging. The implementation of empiric antibiotic therapy is based on old recommendations proposing the combination of a molecule targeting methicillin-resistant Staphylococcus aureus and a betalactamin active on P. aeruginosa, and also adapting this probabilistic treatment by carrying out a microbiological register on a local scale, which is rarely done. In our hemodialysis center at Bordeaux University Hospital, an analysis of the microorganisms causing all catheter-related bloodstream infection over the period 2018-2020 enabled us to propose, in agreement with the infectious disease specialists, an adapted probabilistic antibiotic therapy protocol. This approach allowed us to observe a low incidence of meticillinoresistance of Staphylococcus. For catheters inserted more than 6 months ago, we observed no Staphylococcus, no multi-resistant Pseudomonas, and only 2% of Enterobacteria resistant to cephalosporins. A frequent updating of the microbiological epidemiology of catheter-related bloodstream infection, in partnership with the infectious diseases team in each hemodialysis center, allowing an adaptation of the probabilistic antibiotic therapy, and seems to have a good feasibility. This strategy might favor the preservation of microbial ecology on an individual and collective scale in maintenance hemodialysis patients.
Assuntos
Bacteriemia , Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateteres Venosos Centrais , Staphylococcus aureus Resistente à Meticilina , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Bacteriemia/epidemiologia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/tratamento farmacológico , Infecções Relacionadas a Cateter/epidemiologia , Cateterismo Venoso Central/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Humanos , Diálise Renal/efeitos adversosRESUMO
BACKGROUND: In patients with atopic dermatitis (AD), Staphylococcus aureus frequently colonizes lesions and is hypothesized to be linked to disease severity and progression. Treatments that reduce S. aureus colonization without significantly affecting the skin commensal microbiota are needed. METHODS AND FINDINGS: In this study, we tested ATx201 (niclosamide), a small molecule, on its efficacy to reduce S. aureus and propensity to evolve resistance in vitro. Various cutaneous formulations were then tested in a superficial skin infection model. Finally, a Phase 2 randomized, double-blind and placebo-controlled trial was performed to investigate the impact of ATx201 OINTMENT 2% on S. aureus colonization and skin microbiome composition in patients with mild-to-severe AD (EudraCT:2016-003501-33). ATx201 has a narrow minimal inhibitory concentration distribution (.125-.5 µg/ml) consistent with its mode of action - targeting the proton motive force effectively stopping cell growth. In murine models, ATx201 can effectively treat superficial skin infections of methicillin-resistant S. aureus. In a Phase 2 trial in patients with mild-to-severe AD (N = 36), twice-daily treatment with ATx201 OINTMENT 2% effectively reduces S. aureus colonization in quantitative colony forming unit (CFU) analysis (primary endpoint: 94.4% active vs. 38.9% vehicle success rate, p = .0016) and increases the Shannon diversity of the skin microbiome at day 7 significantly compared to vehicle. CONCLUSION: These results suggest that ATx201 could become a new treatment modality as a decolonizing agent.
Assuntos
Dermatite Atópica , Staphylococcus aureus Resistente à Meticilina , Microbiota , Infecções Estafilocócicas , Animais , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Dermatite Atópica/tratamento farmacológico , Dermatite Atópica/patologia , Humanos , Camundongos , Niclosamida/farmacologia , Pomadas/farmacologia , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureusRESUMO
OBJECTIVES: To investigate the high prevalence of extended-spectrum beta-lactamase (ESBL)-producing strains of Escherichia coli (4%, 10/250 consecutive isolates) recovered during a 5 month period in the maternity ward of the University Hospital of Bordeaux, France. METHODS: beta-Lactam resistance transfer was analysed by conjugation and transformation. ESBLs were characterized by isoelectric focusing, PCR amplification and sequencing. The relatedness of the strains was examined by PFGE and phylogenetic group determination. Plasmids were characterized by incompatibility group and restriction analysis. RESULTS: Ten ESBL-producing E. coli were isolated from urinary or genital samples of eight mothers and from gastric fluids of two newborns of carrier mothers. The patients were hospitalized in five different units of the maternity ward. Transconjugants, obtained for 7 of the 10 strains, and wild-type strains exhibited various antibiotypes. Different CTX-M enzymes were characterized: CTX-M-1 (n = 4); CTX-M-14 (n = 3); CTX-M-32 (n = 2); and CTX-M-28 (n = 1). The strains recovered from two mothers and their respective babies were identical. All the other strains were epidemiologically unrelated. Furthermore, various plasmids were identified. Environmental samples from the common echographic and sampling rooms did not reveal the presence of ESBL-producing enterobacteria. CONCLUSIONS: The data argue against the occurrence of a nosocomial outbreak and support the hypothesis of an importation of community-acquired ESBL-producing strains into the hospital through colonized/infected patients. At present, not only patients transferred from other hospitals or long-term care facilities are at risk of carrying ESBL-producing enterobacteria on hospital admission, but also community patients.
Assuntos
Infecções por Escherichia coli/microbiologia , Infecções por Escherichia coli/transmissão , Proteínas de Escherichia coli/biossíntese , Escherichia coli/enzimologia , Transmissão Vertical de Doenças Infecciosas , beta-Lactamases/biossíntese , Adulto , Antibacterianos/farmacologia , Técnicas de Tipagem Bacteriana , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/transmissão , Impressões Digitais de DNA , Eletroforese em Gel de Campo Pulsado , Microbiologia Ambiental , Escherichia coli/classificação , Escherichia coli/efeitos dos fármacos , Escherichia coli/isolamento & purificação , Infecções por Escherichia coli/epidemiologia , Feminino , França/epidemiologia , Genótipo , Maternidades , Hospitais Universitários , Humanos , Recém-Nascido , Testes de Sensibilidade Microbiana , Plasmídeos/análise , Gravidez , beta-Lactamases/classificação , beta-Lactamas/farmacologiaRESUMO
Background: Extended-spectrum beta-lactamases-producing Enterobacterales (ESBL-E) are disseminating worldwide especially in Intensive Care Units (ICUs) and are responsible for increased health costs and mortality. The aims of this work were to study ESBL-E dissemination in ICU and to assess the impact of ESBL-E fecal carriage on subsequent infections during a non-outbreak situation. Methods: We therefore screened every patient at admission then once a week in a medical ICU between January and June 2015. Each ESBL-E isolate was characterized by ESBL genes PCR amplification and the clonal dissemination was assessed by Pulsed-Field Gel Electrophoresis (PFGE). Results: Among the 608 screened patients, 55 (9%) were colonized by ESBL-E. Forty-four isolates were available for further analysis. Most of them (43/44, 98%) contained a ESBL gene from the CTX-M group. Only one case of ESBL-E cross-transmission occurred, even for acquired ESBL-E colonization. Subsequent infection by ESBL-E occurred in 6/55 (11%) patients and infecting ESBL-E strains were the colonizing ones. ESBL-E faecal carriage had a negative predictive value of 100% and a positive predictive value of 40% to predict ESBL-E ventilator associated-pneumonia (VAP). Alternatives to carbapenems consisting in piperacillin-tazobactam, ceftolozane-tazobactam and ceftazidime-avibactam were all active on this panel of ESBL-E. Conclusions: ESBL-E expansion and acquisition in ICU in a non-outbreak situation are not any more fully explained by cross-transmission. Mechanisms underlying ESBL-E dissemination in ICU are still to investigate. Interestingly, as far as we know, our study demonstrates for the first time by PFGE that the colonizing strain is indeed the infecting one in case of subsequent ESBL-E infection. Nevertheless, subsequent ESBL-E infection remains a rare event conferring poor positive predictive value for ESBL-E colonization to predict ESBL-E VAP. Relevance of systematic ESBL-E faecal screening at ICU admission and during ICU stay needs further investigation.
Assuntos
Infecção Hospitalar/epidemiologia , Infecção Hospitalar/transmissão , Infecções por Enterobacteriaceae/epidemiologia , Infecções por Enterobacteriaceae/transmissão , Enterobacteriaceae/metabolismo , beta-Lactamases/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Proteínas de Bactérias/genética , Proteínas de Bactérias/metabolismo , Carbapenêmicos/farmacologia , Portador Sadio , Eletroforese em Gel de Campo Pulsado , Enterobacteriaceae/efeitos dos fármacos , Enterobacteriaceae/genética , Enterobacteriaceae/isolamento & purificação , Infecções por Enterobacteriaceae/microbiologia , Fezes/microbiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , beta-Lactamases/metabolismoRESUMO
BACKGROUND: In a previous study of subjects suspected of having ventilator-associated pneumonia, a rapid susceptibility testing approach by using ETEST (BioMérieux) strips directly applied to bronchoalveolar lavage samples provided valuable information at hour 24. The primary objective of this study was to assess a new direct specimen testing by using an even more-rapid E-test approach (at hour 10), which could promote an early de-escalation of the antimicrobial therapy. METHODS: Twenty-eight subjects with ventilator-associated pneumonia admitted to a medical ICU were prospectively included. In parallel with standard routine methods, E-test strips were directly applied onto agar plates seeded with bronchoalveolar lavage samples and were analyzed after 10 h of incubation. E-test results were used to identify potential drug choices by simulating clinical decision making if the microscopy results had been available at the point of care. These choices were analyzed for concordance with the narrowest adequate antimicrobial therapy according to the Minimum Inhibitory Concentrations (MICs) provided by the reference method (ie, the laboratory routine diagnostic). RESULTS: At hour 10, direct specimen testing was readable in 18 of 28 bronchoalveolar lavage samples (64%). Total agreement between the 10-h direct specimen testing approach and the laboratory routine diagnostic approach was 90%, with a sensitivity of 83% and a specificity of 95%, with 8% major errors and 3% very major errors. The concordance between the 2 tests was very good (kappa = 0.79). If the 10-h E-test results were taken into account, then an early de-escalation strategy would have been possible in 10 of 18 cases (55%) at hour 10. CONCLUSIONS: This rapid susceptibility testing approach provided early (10 h) and valuable information that could lead to an early adjustment of empirical antimicrobial treatment in a ventilator-associated pneumonia setting. (ClinicalTrials.gov registration NCT01266863.).
Assuntos
Antibacterianos/farmacologia , Líquido da Lavagem Broncoalveolar/microbiologia , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/microbiologia , Idoso , Antibacterianos/uso terapêutico , Estudos de Coortes , Diagnóstico Precoce , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Testes de Sensibilidade Microbiana/métodos , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/diagnóstico , Estudos Prospectivos , Sensibilidade e Especificidade , Fatores de TempoRESUMO
BACKGROUND: This study was undertaken to determine the temporal relationship between implementation of different interventions in an intensive care unit (ICU) and control of endemic nosocomial acquisition of extended-spectrum ß-lactamase Enterobacteriaceae (ESBLE). METHODS: This was a prospective observational study with time-series analysis of the monthly incidence of ESBLE and its predictors. In November 2007, after a 14-month baseline period, an intervention consisting of restriction of third-generation cephalosporins (3 GC) and increased use of alcohol-based hand rubs was implemented. In January 2008, an increased health care worker (HCW):patient ratio was also implemented. In March 2010, the ICU was closed, and patients were moved to a clean ICU. RESULTS: The first intervention resulted in global reduction in 3 GC and increased use of alcohol-based hand rub. A significant change in ESBLE incidence was observed in a full segmented univariate regression analysis (mean change in level, -0.91 ± 0.19; P < .0001). After ICU closure, there was a dramatic reduction in ESBLE acquisition. According to the multivariate model, the ICU closure was the main protective factor. Before ICU closure, an increase in the HCW:patient ratio of 0.1 point tended to be associated with a decreased risk of ESBLE acquisition (relative risk, 0.28; 95% confidence interval, 0.06-1.25; P = .09). CONCLUSIONS: This study shows that ICU closure was associated with, but not necessarily the reason for, control of ESBLE cross-transmission in a nonoutbreak setting. Environmental ESBE sources may play a role in cross-transmission.