[What is confirmed in therapy of complicated urinary tract infections]. / Was ist gesichert in der Therapie der komplizierten Harnwegsinfektionen.

Urinary tract infections (UTI) rank among the most common bacterial infections worldwide. Clinical challenges include acute severe manifestations and frequently relapsing disease, both favored by urinary tract abnormalities and systemic immune defects. To judge morbidity during clinical infection, the ORENUC criteria assess clinical risk, likelihood of relapsing disease, extragenital manifestations, nephropathy, urologic and catheter-related factors. Additional diagnostic measures of severe and unusual manifestations include an extended history and specific clinical examination together with nephro-urological imaging, namely ultrasound, laboratory assessment of systemic disease, and removal or exchange of catheters and other foreign materials in the urinary tract. The current primary antibiotics recommended for uncomplicated pyelonephritis in Germany are gyrase inhibitors and cephalosporins. Microbiological diagnosis and resistance testing is central to improve efficacy and reduce side effects, especially in complex clinical situations. New antibiotic developments offer new options, especially in presence of proven antimicrobial resistance. Management of relapsing infections needs to aim at improvement of local urogenital and systemic immunological factors, which is however frequently challenging to impossible to achieve. Patient contributions including behavioral modifications and longterm or intermittent antibiotic and other drug therapy. Overall, therapeutic options are limited and new pathophysiological and antimicrobial strategies are urgently needed.

Mycoplasma genitalium treatment outcomes among a cohort failing macrolide resistance-guided treatment across three London sexual health clinics.

OBJECTIVE: British guidelines advise treatment of Mycoplasma genitalium (Mgen) infection using the results of macrolide resistance-associated mutation (MRAM) assays. Limited data informs management when patients fail MRAM-guided treatment. This study evaluates current management strategies employed for cases of Mgen infection with MRAM-guided treatment failure. DESIGN: This retrospective analysis reviewed laboratory and clinical data pertaining to all positive Mgen results between 28 May 2020 and 05 November 2022 across three London sexual health clinics. Treatment failure was defined as microbiological or clinical failure, despite appropriate MRAM-guided treatment with full compliance and no re-infection risk. Where MRAM status was unable to be determined, samples were excluded. RESULTS: 340 samples were included from mostly male (74.4%) patients with a mean age of 30 years. The majority of tests were sent for urethritis (63.8%), and most infections were present without concurrent STIs (83.5%). 183 (53.8%) samples were MRAM positive; 157 (46.1%) were wild type. 152/183 (83.1%) received MRAM-guided treatment. 49/152 (32.2%) cases of MRAM-guided treatment failure were identified. 32/49 (65.3%) achieved either microbiological or clinical cure through a variety of treatment regimens. 66.6% of nine patients who received pristinamycin achieved microbiological cure; two patients were cured by minocycline. Many patients received multiple courses of moxifloxacin despite previous failures. CONCLUSION: Whilst high compliance with recommended MRAM-guided therapy was identified, there were also high rates of quinolone therapy failure (32.2%). Barriers to appropriate treatment include a lack of quinolone resistance assays and the non-availability of sitafloxacin in Europe, along with the limited availability of pristinamycin and minocycline in the UK during the study dates. We recommend developing a standardised management pathway for treatment resistant cases.

Unnecessary antibiotic use in men who have sex with men (MSM) with anogenital symptoms attending a sexual health clinic: a retrospective analysis.

OBJECTIVES: To quantify the amount of unnecessary antibiotics, in particular ceftriaxone, given to men who have sex with men (MSM) with anogenital symptoms as part of presumptive management in an urban sexual health clinic and examine factors associated with unnecessary ceftriaxone. METHODS: This is a retrospective cross-sectional analysis of electronic records from all visits involving MSM reporting symptoms of bacterial sexually transmitted infection (STI) and who received presumptive antibiotics at Sydney Sexual Health Centre. The following variables were extracted: demographic and sexual behaviour data, presenting symptoms, prior STI diagnoses, use of anoscopy, use of point-of-care microscopy, prescriptions of antibiotics and subsequent nucleic acid amplification testing (NAAT) results for chlamydia and gonorrhoea in all anatomical sites (urethra, pharynx and rectum). We defined unnecessary antibiotic as an agent prescribed to treat an STI organism that was subsequently not detected. RESULTS: Among 1061 visits in this analysis, 41.8% yielded negative NAAT results for both chlamydia and gonorrhoea in all anatomical sites. There were 44.3% of visits which had positive gonorrhoea NAAT result in at least one anatomical site. There were 187 courses of ceftriaxone prescribed in patients who tested negative for gonorrhoea in all anatomical sites and therefore were unnecessary. Unnecessary ceftriaxone prescribing occurred in 50.2% of visits with anorectal symptoms, 19.6% of scrotal symptoms and 7.3% of urethral symptoms. Microscopy was associated with significantly less unnecessary ceftriaxone in urethral but not anorectal or scrotal presentations. In multivariable analysis, the following factors were associated with a higher likelihood of unnecessary ceftriaxone use: anorectal symptoms, scrotal symptoms, gonorrhoea in the preceding year, contact of a bacterial STI and living with HIV. CONCLUSIONS: This study highlights the significant amount of unnecessary ceftriaxone used for STI symptoms in MSM. A new pathway incorporating rapid point-of-care molecular testing in symptomatic patients may improve the precision of antibiotic prescribing and reduce unnecessary use.

Molecular detection of ceftriaxone resistance in Neisseria gonorrhoeae clinical specimens: a tool for public health control.

OBJECTIVES: This study aimed to validate and implement a rapid screening assay for molecular detection of the penA-60 allele that is associated with ceftriaxone resistance in Neisseria gonorrhoeae for use on both isolate lysates and clinical specimen DNA extracts. METHODS: A N. gonorrhoeae penA real-time (RT)-PCR was adapted to include a species-specific pap confirmation target and a commercially available internal control to monitor for PCR inhibition.The modified assay was validated using N. gonorrhoeae-positive (n=24) and N. gonorrhoeae-negative (n=42) clinical specimens and isolate lysates. The panel included seven samples with resistance conferred by penA alleles targeted by the assay and four samples with different penA alleles. The feasibility of using the penA RT-PCR for molecular surveillance was assessed using clinical specimens from 54 individuals attending a London sexual health clinic who also had a N. gonorrhoeae isolate included in the 2020 Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). RESULTS: The assay correctly identified N. gonorrhoeae specimens (n=7) with penA-60/64 alleles targeted by the assay. No penA false negatives/positives were detected, giving the penA target of the assay a sensitivity, specificity, positive and negative predicted values (PPV, NPV) of 100% (95% CIs; sensitivity; 56.1-100%, specificity; 93.6-100%, PPV; 56.1-100%, NPV; 93.6-100%).No cross-reactivity with other Neisseria species or other urogenital pathogens was detected. The N. gonorrhoeae target (pap) was detected in 73 out of 78 of the N. gonorrhoeae-positive specimens, resulting in 92.6% sensitivity (95% CI 83.0% to 97.3%), 100% specificity (95% CI 75.9% to 100%) and PPV, and a NPV of 89.4% (95% CI 52.5% to 90.9%). No penA-59/60/64 alleles were detected within the clinical specimens from the GRASP 2020 feasibility molecular surveillance study (n=54 individuals). CONCLUSION: The implementation of this PCR assay for patient management, public health and surveillance purposes enables the rapid detection of gonococcal ceftriaxone resistance conferred by the most widely circulating penA alleles.

Impact of molecular ciprofloxacin resistance testing in management of gonorrhoea in a large urban clinic.

OBJECTIVES: Antibiotic resistance in gonorrhoea is of significant public health concern with the emergence of resistance to last-line therapies such as ceftriaxone. Despite around half of Neisseria gonorrhoeae isolates tested in the UK being susceptible to ciprofloxacin, very little ciprofloxacin is used in clinical practice. Testing for the S91F mutation associated with ciprofloxacin resistance is now available in CE-marked assays and may reduce the requirement for ceftriaxone, but many patients are treated empirically, or as sexual contacts, which may limit any benefit. We describe the real-world impact of such testing on antimicrobial use and clinical outcomes in people found to have gonorrhoea in a large urban UK sexual health clinic. METHODS: Molecular ciprofloxacin resistance testing (ResistancePlus GC assay (SpeeDx)) was undertaken as an additional test after initial diagnosis (m2000 Realtime CT/NG assay (Abbott Molecular)) in those not already known to have had antimicrobial treatment. Data from a 6-month period (from March to September 2022) were analysed to determine treatment choice and treatment outcome. RESULTS: A total of 998 clinical samples tested positive for N. gonorrhoeae in 682 episodes of infection. Of the 560 (56%) samples eligible for resistance testing, 269 (48.0%) were reported as wild-type, 180 (32.1%) were predicted to be resistant, 63 (11.3%) had an indeterminate resistance profile, and in 48 (8.6%) samples, N. gonorrhoeae was not detected. Ciprofloxacin was prescribed in 172 (75%) of 228 episodes in which the wild-type strain was detected. Four (2%) of those treated with ciprofloxacin had a positive test-of-cure sample by NAAT, with no reinfection risk. All four had ciprofloxacin-susceptible infection by phenotypic antimicrobial susceptibility testing. CONCLUSIONS: In routine practice in a large UK clinic, molecular ciprofloxacin resistance testing led to a significant shift in antibiotic use, reducing use of ceftriaxone. Testing can be targeted to reduce unnecessary additional testing. Longer term impact on antimicrobial resistance requires ongoing surveillance.

Clinical scoring model for predicting cefotaxime-resistance in Klebsiella pneumoniae bacteremia: development and validation based on portal of entry.

We developed a prediction model for cefotaxime resistance in patients with K. pneumoniae bacteremia. Adult patients with K. pneumoniae bacteremia were grouped into derivation (from March 2018 to December 2019) and validation (from January 2020 to August 2020) cohorts. The prediction scoring system was based on factors associated with cefotaxime resistance identified by the logistic regression model. A total of 358 patients were enrolled (256 for derivation, 102 for validation). In the multivariable analysis, age ≥65 years, hospital-acquired infection, prior antimicrobial use, and an updated Charlson comorbidity index ≥3 points were associated with cefotaxime resistance in the derivation cohort. When each variable was counted as 1 point, the values of the area under the curve were 0.761 in the derivation and 0.781 in the validation cohorts. The best cutoff value using the Youden index was ≥2 with 73.6% sensitivity and 67.5% specificity. Our simple scoring system favorably predicted cefotaxime resistance.

Minimum inhibitory concentrations of Neisseria gonorrhoeae strains in clients of the Amsterdam sexual health clinic with a Dutch versus an international sexual network.

OBJECTIVES: International travel combined with sex may contribute to dissemination of antimicrobial-resistant (AMR) Neisseria gonorrhoeae (Ng). To assess the role of travel in Ng strain susceptibility, we compared minimum inhibitory concentrations (MICs) for five antibiotics (ie, azithromycin, ceftriaxone, cefotaxime, cefixime and ciprofloxacin) in strains from clients with an exclusively Dutch sexual network and clients with an additional international sexual network. METHODS: From 2013 to 2019, we recorded recent residence of sexual partners of clients (and of their partners) with Ng at the Center for Sexual Health of Amsterdam. We categorised clients as having: (1) exclusively sexual partners residing in the Netherlands ('Dutch only') or (2) at least one partner residing outside the Netherlands. We categorised the country of residence of sexual partners by World Bank/EuroVoc regions. We analysed the difference of log-transformed MIC of Ng strains between categories using linear or hurdle regression for each antibiotic. RESULTS: We included 3367 gay and bisexual men who had sex with men (GBMSM), 516 women and 525 men who exclusively had sex with women (MSW) with Ng. Compared with GBMSM with a 'Dutch only' network, GBMSM with: (1) a Western European network had higher MICs for ceftriaxone (ß=0.19, 95% CI=0.08 to 0.29), cefotaxime (ß=0.19, 95% CI=0.08 to 0.31) and cefixime (ß=0.06, 95% CI=0.001 to 0.11); (2) a Southern European network had a higher MIC for cefixime (ß=0.10, 95% CI=0.02 to 0.17); and (3) a sub-Saharan African network had a lower MIC for ciprofloxacin (ß=-1.79, 95% CI=-2.84 to -0.74). In women and MSW, higher MICs were found for ceftriaxone in clients with a Latin American and Caribbean network (ß=0.26, 95% CI=0.02 to 0.51). CONCLUSIONS: For three cephalosporin antibiotics, we found Ng strains with slightly higher MICs in clients with partner(s) from Europe or Latin America and the Caribbean. International travel might contribute to the spread of Ng with lower susceptibility. More understanding of the emergence of AMR Ng is needed.

How to Defeat Multidrug-Resistant Bacteria in Intensive Care Units. A Lesson from the COVID-19 Pandemic. Prevention, Reservoirs, and Implications for Clinical Practice.

Background: Intensive care unit (ICU) patients are at high risk of infection due to multiple invasive procedures, malnutrition, or immunosuppression. The rapid increase in infections with multidrug-resistant organisms (MDRO) during the COVID-19 pandemic caused a dilemma, as the rules of the sanitary regime in ICU rooms were strictly adhered to in the prevailing epidemiological situation. The combat to reduce the number of infections and pathogen transmission became a priority for ICU staff. This study aimed to assess whether eliminating environmental reservoirs and implementing improved procedures for patient care and decontamination and washing equipment in the ICU reduced the incidence of infections caused by MDR strains. Material and methods: The study retrospectively analyzed data in the ICU during the COVID-19 pandemic. The samples were collected based on microbiological culture and medical records in the newly opened ICU (10 stations) and hospital wards where COVID-19 patients were hospitalized. Environmental inoculations were performed during the COVID-19 pandemic every 4-6 weeks unless an increase in the incidence of infections caused by MDR strains was observed. Through microbiological analysis, environmental reservoirs of MDR pathogens were identified. The observation time was divided into two periods, before and after the revised procedures. The relationship between isolated strains of Klebsiella pneumoniae NDM from patients and potential reservoirs within the ICU using ERIC-PCR and dice methods was analyzed. Results: An increased frequency of infections and colonization caused by MDRO was observed compared to the preceding years. A total of 23,167 microbiological tests and 6,985 screening tests for CPE and MRSA bacilli were collected. The pathogen spread was analyzed, and the findings indicated procedural errors. Assuming that the transmission of infections through the staff hands was significantly limited by the restrictive use of personal protective equipment, the search for a reservoir of microorganisms in the environment began. MDR strains were grown from the inoculations collected from the hand-wash basins in the wards and from inside the air conditioner on the ceiling outside the patient rooms. New types of decontamination mats were used in high-risk areas with a disinfectant based on Glucoprotamine. Active chlorine-containing substances were widely used to clean and disinfect surfaces. Conclusions: Infections with MDR strains pose a challenge for health care. Identification of bacterial reservoirs and comprehensive nursing care significantly reduce the number of nosocomial infections.

Antimicrobial susceptibility profile of Neisseria gonorrhoeae from patients attending a medical laboratory, Institut Pasteur de Madagascar between 2014 and 2020: phenotypical and genomic characterisation in a subset of Neisseria gonorrhoeae isolates.

OBJECTIVES: Antimicrobial-resistant Neisseria gonorrhoeae (NG) is a concern. Little is known about antimicrobial susceptibility profiles and associated genetic resistance mechanisms of NG in Madagascar. We report susceptibility data of NG isolates obtained by the medical laboratory (CBC) of the Institut Pasteur de Madagascar, Antananarivo, Madagascar, during 2014-2020. We present antimicrobial resistance mechanisms data and phenotype profiles of a subset of isolates. METHODS: We retrieved retrospective data (N=395) from patients with NG isolated during 2014-2020 by the CBC. We retested 46 viable isolates including 6 found ceftriaxone and 2 azithromycin resistant, as well as 33 isolated from 2020. We determined minimal inhibitory concentrations for ceftriaxone, ciprofloxacin, azithromycin, penicillin, tetracycline and spectinomycin using Etest. We obtained whole-genome sequences and identified the gene determinants associated with antimicrobial resistance and the sequence types (STs). RESULTS: Over the study period, ceftriaxone-resistant isolates exceeded the threshold of 5% in 2017 (7.4% (4 of 54)) and 2020 (7.1% (3 of 42)). All retested isolates were found susceptible to ceftriaxone, azithromycin and spectinomycin, and resistant to ciprofloxacin. The majority were resistant to penicillin (83% (38 of 46)) and tetracycline (87% (40 of 46)). We detected chromosomal mutations associated with antibiotic resistance in gyrA, parC, penA, ponA, porB and mtrR genes. None of the retested isolates carried the mosaic penA gene. The high rate of resistance to penicillin and tetracycline is explained by the presence of bla TEM (94.7% (36 of 38)) and tetM (97.5% (39 of 40)). We found a high number of circulating multilocus STs. Almost half of them were new types, and one new type was among the four most predominant. CONCLUSIONS: Our report provides a detailed dataset obtained through phenotypical and genotypical methods which will serve as a baseline for future surveillance of NG. We could not confirm the occurrence of ceftriaxone-resistant isolates. Our results highlight the importance of implementing quality-assured gonococcal antimicrobial resistance surveillance in Madagascar.

Analysis of current status and risk factors of multidrug-resistant bacteria wound infections in patients with autoimmune bullous diseases / 中华皮肤科杂志

Objective:To investigate the current status of multidrug-resistant bacteria (MDRO) wound infections in patients with autoimmune bullous diseases (AIBDs), and to analyze their risk factors.Methods:A retrospective study was conducted, and inpatients with AIBDs accompanied by wound infections were collected from Hospital of Dermatology, Chinese Academy of Medical Sciences from January 2020 to December 2022. A descriptive analysis was carried out to analyze the basic characteristics of these patients and pathogenic characteristics of MDRO. Univariate and binary logistic regression models were used to analyze independent risk factors for MDRO infections in patients with AIBDs. Differences between the MDRO infection group and common bacterial infection group were analyzed by using t test, Mann-Whitney U test and chi-square test. Results:Totally, 271 patients with AIBDs accompanied by wound infections were included, including 159 males (58.7%) and 112 females (41.3%), and 142 patients (52.4%) were aged over 60 years. Most patients with AIBDs were diagnosed with pemphigus vulgaris (131 cases, 48.3%), or bullous pemphigoid (99 cases, 36.5%). Bacterial culture was positive in all the patients, and 74 (27.3%) were infected with MDRO; a total of 108 strains of MDRO were detected, with relatively high detection rates of Staphylococcus (82 strains, 75.9%) and Enterobacter (15 strains, 13.9%). Significant differences were observed between the MDRO infection group and the common bacterial infection group in the duration of hospitalization, involved body surface area, proportions of patients self-modificating drug dosage, proportions of patients topically using antibiotic ointments, proportions of patients using immunosuppressants, duration of glucocorticoid use, maximum dose of glucocorticoids and the first albumin level at admission (all P < 0.05), while there were no significant differences in the gender, age, proportions of patients at first hospitalization, types of AIBDs, duration of education, body mass index, disease duration, proportions of smoking patients, proportions of drinking patients, proportions of patients with comorbid chronic diseases, surgical history, prevalence of hypoalbuminemia, prevalence of mucosal involvement, proportions of patients receiving topical glucocorticoids, proportions of patients using biological agents, duration of antibiotic use, and the first total protein level at admission between the two groups (all P > 0.05). Logistic regression analysis showed that the use of topical antibiotic ointments, use of immunosuppressants, maximum dose of glucocorticoids, and self-modification of drug dosage were independent risk factors for MDRO infections (all P < 0.05) . Conclusions:The patients with AIBDs were prone to develop MDRO infections in wounds, and Staphylococcus infections were the most common. The use of topical antibiotic ointments, use of immunosuppressants, high dose of glucocorticoids, and self-modification of drug dosage may increase the risk of infections in patients with AIBDs.

Developing a model of information transfer practice between institutions targeted at primary health care patients who are asymptomatic carriers of carbapenemase producing Enterobacteriacae.

BACKGROUND: Drug-resistant bacteria are one of the main reasons of deaths worldwide. A significant group of these bacteria are carbapenemase producing Enterobacteriaceae (CPE). The goal of this study was to develop a diagnostic and therapeutic model targeted at asymptomatic carriers of CPE. MATERIAL AND METHODS: A team of experts from different branches connected to health care, discussing the topic based on the data collected from previous research. Working sessions were dispersed between June and December 2022. The consensus has been reached via repeated discussion and literature search. RESULTS: The facility where CPE are detected is required to create an alert pathogen note and to notify sanitary-epidemiological station and National Reference Centre for Antimicrobial Susceptibility of Microorganisms - neither these institutions, nor the patient are required to notify the primary care physician. In primary care clinics, it is possible to work towards breaking the transmission of CPE by educating patients with CPE and persons who were in contact with them, and to undertake actions in order to look for patients with risk factors for CPE colonisation. In order to improve communication between individual levels of the health care system, standardised information could be introduced to the discharge note about a case of CPE, which will be electronically transmitted to the primary care facility. It might contribute to effective combating of the spread of CPE, by serving as a source of knowledge and education for patients and by checking the patient's risk factors, which will improve the performance of tests for CPE colonisation. CONCLUSIONS: The established model of good practice requires a change of legal regulations and its implementation, which will reduce the spread of CPE in health care facilities and will enable its future improvement. Med Pr Work Health Saf. 2023;74(4):263-70.

Increasing proportions of extended-spectrum ß-lactamase-producing isolates among Escherichia coli from urine and bloodstream infections: results from a nationwide surveillance network, Finland, 2008 to 2019.

BackgroundEscherichia coli is the leading cause of urinary tract infections (UTI) and bloodstream infections (BSI), and the emergence of antimicrobial resistance (AMR) in E. coli causes concern.AimTo investigate changes in the proportion of extended-spectrum ß-lactamase (ESBL) producing isolates among E. coli isolated from urine and blood in Finland during 2008-2019.MethodsSusceptibility testing of 1,568,488 urine (90% female, 10% male) and 47,927 blood E. coli isolates (61% female, 39% male) from all Finnish clinical microbiology laboratories during 2008-2019 was performed according to guidelines from the Clinical and Laboratory Standard Institute during 2008-2010 and the European Committee on Antimicrobial Susceptibility Testing during 2011-2019. A binomial regression model with log link compared observed trends over time and by age group and sex.ResultsThe annual proportion of ESBL-producing E. coli isolates among E. coli from blood cultures increased from 2.4% (23/966) to 8.6% (190/2,197) among males (average annual increase 7.7%; 95% CI: 4.4-11.0%, p < 0.01) and from 1.6% (28/1,806) to 6.4% (207/3,218) among females (9.3%; 95% CI: 4.8-14.0%, p < 0.01). In urine cultures, the proportion of ESBL-producing E. coli isolates increased from 2.2% (239/10,806) to 7.2% (1,098/15,297) among males (8.8%; 95% CI: 6.5-11.3%, p < 0.01) and from 1.0% (1,045/108,390) to 3.1% (3,717/120,671) among females (8.6%; 95% CI: 6.3-11.0%, p < 0.01). A significant increase was observed within most age groups.ConclusionsConsidering the ageing population and their risk of E. coli BSI and UTI, the increase in the annual proportions of ESBL-producing E. coli is concerning, and these increasing trends should be carefully monitored.

Changes in prevalence of Mycoplasma genitalium macrolide and fluoroquinolone resistance: notes from a 13-year retrospective survey in Dalarna County, Sweden.

OBJECTIVE: Macrolide and fluoroquinolone resistance in Mycoplasma genitalium (MG) is of emerging global concern. Compared with neighbouring countries such as Denmark, Sweden has had lower rates of macrolide resistance while fluoroquinolone resistance rates are less well documented. This study retrospectively examined macrolide, fluoroquinolone and multidrug resistance rates from Dalarna County, Sweden over a 13-year period. METHODS: MG-positive samples from 2006 to 2018 from patients examined at the Department of Venereology, Central Hospital, Falun, Sweden were tested by sequencing for macrolide resistance mutations (MRM) and fluoroquinolone resistance-associated mutations (QRAM) in the parC and gyrA subunit regions. A subset of these samples from 2006 to 2011 have been reported on previously, although only for MRM. RESULTS: Of 874 samples, 98 (11.2%, 95% CI 9.1% to 13.6%) had mutations associated with resistance to macrolides and 19 of 828 (2.3%, 95% CI 8.9% to 23.1%) to quinolones. Mutations associated with resistance to both drugs were detected in 5 of 828 (0.6%, 95% CI 0.1% to 1.4%) samples overall. A significant positive linear trend (p=0.004) for an increase in the rate of macrolide resistance was observed (from 0% in 2006 to 31% in 2018) while the increase in QRAM from 0% in 2006 to 12.3% in 2018 was not statistically significant. CONCLUSIONS: Despite a decrease in macrolide and fluoroquinolone consumption in Sweden, there was an overall increase in MG macrolide, fluoroquinolone and dual resistance from 2006 to 2018, although the difference in fluoroquinolone resistance rates was not statistically significant. In order to maintain comparably low resistance rates, resistance-guided therapy for MG infections will be crucial.

[Gram-negative bacteria of critical priority in ICU patients from a tertiary care hospital]. / Bacterias Gram-negativas de prioridad crítica en pacientes de las UCI de un hospital de tercer nivel.

Background: Intensive care units (ICU) are the epicenter of antimicrobial resistance (AMR), and patients' infections are mainly caused by Gram-negative bacteria (GNB). Objective: To describe the frequency and trends in AMR of GNB deriving from the clinical samples of ICU patients at a tertiary care hospital in Mérida, Yucatán. Material and methods: Study which included the review of laboratory reports of all bacteriological samples collected from patients admitted to neonatal, pediatric and adult ICU from January 1 2019 to December 31 2021. Results: 433 GNB isolates were recovered, with Klebsiella pneumoniae being the most predominant isolate (n = 117; 27.02%). The majority of GNB were recovered from bronchial secretions (n = 163). Overall, GNB showed high resistance rates to ampicillin (89.48%), ampicillin/sulbactam (66.85%), cephalosporins (58.52-93.81%), tobramycin (58.06%), and tetracycline (61.73%). Among GNB, 73.90% and 68.53% exhibited multidrug-resistant, and highly resistant microorganisms' profiles, respectively, and 47.54% of Acinetobacter baumannii exhibited an extensively drug-resistant profile. A total of 80.33% of A. baumannii was carbapenem-resistant, and 83.76% of K. pneumoniae strains were ESBL-producing. Conclusion: Our data could be helpful to improve the empirical therapy and the infection-control program.

Introducción: las unidades de cuidados intensivos (UCI) son el epicentro de la resistencia a los antimicrobianos (RAM) y las infecciones en estas áreas son causadas principalmente por bacterias Gram-negativas (BGN). Objetivo: describir la frecuencia y los patrones de RAM en BGN aisladas de muestras clínicas de pacientes de las UCI de un hospital de tercer nivel en Mérida, Yucatán. Material y métodos: estudio que incluyó la revisión de los reportes de laboratorio de las muestras bacteriológicas obtenidas de pacientes ingresados en las UCI neonatal, pediátrica y adulta del 1 de enero de 2019 al 31 de diciembre de 2021. Resultados: se identificaron 433 BGN y Klebsiella pneumoniae fue el patógeno más prevalente (n = 117; 27.02%). La mayoría de las BGN aisladas se obtuvieron de secreciones bronquiales (n = 163). En general, las BGN mostraron altas tasas de resistencia a ampicilina (89.48%), ampicilina/sulbactam (66.85%), cefalosporinas (58.52-93.81%), tobramicina (58.06%) y tetraciclina (61.73%). El 73.90% y el 68.53% de las BGN exhibieron perfiles multidrogorresistentes y microorganismos altamente resistentes a fármacos, respectivamente, y 47.54% de los aislamientos de Acinetobacter baumannii mostró perfil de drogorresistencia extendida. El 80.33% de los A. baumannii fue resistente a carbapenémicos y el 83.76% de las K. pneumoniae fueron productoras de BLEE. Conclusión: nuestros datos podrían mejorar la terapia antimicrobiana empírica y el programa de control de infecciones.

Caracterización de ß-lactamasas de espectro extendido en aislamientos clínicos colombianos de Salmonella enterica no tifoidea de 1997 a 2022 / Characterization of extended spectrum ß-lactamases in Colombian clinical isolates of non-typhoidal Salmonella enterica between 1997 and 2022

Introducción. Salmonella spp. es un agente patógeno zoonótico transmitido al humano por el agua o los alimentos contaminados. La presencia de ß-lactamasas de espectro extendido es un creciente problema para la salud pública debido a que estas enzimas confieren resistencia contra las cefalosporinas de tercera y cuarta generación. Objetivo. Caracterizar las ß-lactamasas de espectro extendido en aislamientos de Salmonella spp. recibidos por el programa de vigilancia de enfermedad diarreica aguda o enfermedad transmitida por alimentos del Grupo de Microbiología del Instituto Nacional de Salud. Materiales y métodos. Entre enero de 1997 y junio de 2022, se recibieron 444 aislamientos de Salmonella spp. resistentes, por lo menos, a una de las cefalosporinas de tercera generación. El fenotipo de las ß-lactamasas de espectro extendido se identificó con la prueba de doble disco. El ADN se extrajo por ebullición y mediante PCR se amplificaron los genes bla CTX-M, bla SHVy : ' a ILM. Resultados. Todos los aislamientos fueron positivos para la prueba de ß-lactamasas de espectro extendido. Los resultados de la amplificación por PCR fueron: bla CTX-M + bla TLM (n=200), bla CTX-M (n=177), bla SHV(n=16), bla SHV + bla CTX-M (n=6), bla TLM (n=13) y bla SHV + bla CTX-M + bla TLM (n=3). Del total, 26 aislamientos fueron negativos para los genes evaluados. Los aislamientos positivos para ß-lactamasas de espectro extendido se identificaron en Bogotá y en 21 departamentos: Chocó, Magdalena, Meta, Bolívar, Casanare, Cesar, Córdoba, Quindío, Atlántico, Tolima, Cauca, Cundinamarca, Huila, Boyacá, Caldas, Norte de Santander, Risaralda, Antioquia, Nariño, Santander y Valle del Cauca. Conclusión. La resistencia a las cefalosporinas de tercera generación en aislamientos de Salmonella spp. fue generada principalmente por bla CTX-M. El 44 % (197/444) de los aislamientos presentó resistencia a ampicilina, tetraciclina, cloranfenicol y trimetoprim- sulfametoxazol Los serotipos portadores de ß-lactamasas de espectro extendido más frecuentes fueron S. Typhimurium y S. Infantis.

Introduction. Salmonella spp. is a zoonotic pathogen transmitted to humans through contaminated water or food. The presence of extended-spectrum ß-lactamases is a growing public health problem because these enzymes are resistant to third and fourth generation cephalosporins. Objective. To characterize extended-spectrum ß-lactamases in Salmonella spp. isolates received by the acute diarrheal disease/foodborne disease surveillance program of the Grupo de Microbiología of the Instituto Nacional de Salud. Materials and methods. A total of 444 Salmonella spp. isolates, resistant to at least one of the cephalosporins, were obtained between January 1997 and June 2022. The extended- spectrum ß-lactamases phenotype was identified by the double disk test. DNA extraction was carried out by the boiling method, and the bla CTX-M, bla SHV, and bla TLM genes were amplified by PCR. Results. All the isolates were positive for the extended-spectrum ß-lactamases test. The genes identified were: bla CTX-M + ba TLM (n=200), bla CTX-M (n=177), bla SHV(n=16), bla SHV + bla CTX-M (n=6), bla TLM (n=13) and bla SHV + bla CTX-M + bla TLM (n=3). Twenty-six isolates were negative for the evaluated genes. Positive extended-spectrum ß-lactamases isolates were identified in Bogotá and 21 departments: Chocó, Magdalena, Meta, Bolívar, Casanare, Cesar, Córdoba, Quindío, Atlántico, Tolima, Cauca, Cundinamarca, Huila, Boyacá, Caldas, Norte de Santander, Risaralda, Antioquia, Nariño, Santander y Valle del Cauca. Conclusion. Resistance to third generation cephalosporins in Salmonella spp. isolates was mainly caused by bla CTX-M. Isolates were resistant to ampicillin, tetracycline, chloramphenicol, and trimethoprim-sulfamethoxazole (44 %; 197/444). The most frequent extended-spectrum ß-lactamases-expressing serotypes were Salmonella Typhimurium and Salmonella Infantis.

Rats as sources of multidrug-resistant Enterobacteriaceae in animal production environments.

Rattus norvegicus and Rattus rattus are commensal pest rodents, considered reservoirs and vectors of zoonotic pathogens. In livestock farms, the wide use of antimicrobials and their release into the environment lead to high long-term residual concentrations, which may in turn lead to the occurrence of antimicrobial resistance (AMR). Farm environments serve as AMR sources, resulting in the transmission of antimicrobial-resistant bacteria and their AMR genes of livestock origin into wildlife. This study aimed to analyse the profile of enterobacteria carrying AMR determinants in rats captured in livestock farms to determine their potential vectors as for the spread of AMR. To this end, 56 rats (52 R. norvegicus and 4 R. rattus) were live-trapped on 11 farms (pig, dairy, poultry and mixed farms) located in central Argentina, from spring 2016 to autumn 2017. From 50 of the R. norvegicus individuals and three of the R. rattus individuals found in 10 of the farms, we isolated 53 Escherichia coli and five Salmonella strains. Susceptibility to antimicrobials, genotypic profiles, minimal inhibitory concentration of colistin and the presence of mcr-1 and genes encoding extended-spectrum ß-lactamase (ESBL) were determined. Of the 58 isolates not susceptible to different antimicrobial classes, 28 of the E. coli strains and two of the Salmonella strains were defined as multi-drug resistant (MDR). S. Westhampton and S. Newport recovered were not susceptible to ampicillin or all the cephems tested. One of the E. coli obtained showed resistance to colistin and harboured the mcr-1 gene, demonstrated by PCR and conjugation. In two ESBL-producing Salmonella isolated from rats, CTX-M-2 genes were responsible for the observed resistance to third-generation cephalosporins. The MDR E. coli isolates showed several different resistance patterns (23), although some of them were the same in different individuals and different farms, with six resistance patterns, evidencing the dispersion of strains. These findings suggest that rats play a role in the dissemination of AMR determinants between animal, humans and environmental reservoirs.

[Urinary tract infections including pyelonephritis]. / Harnwegsinfektionen einschließlich Pyelonephritis.

Urinary tract infections (UTIs) are among the most common bacterial infections. The clinical phenotypes of UTIs are heterogeneous, ranging from rather benign uncomplicated infections to complicated UTIs and pyelonephritis to severe urosepsis. There has been a sharp increase in the incidence of severe UTIs, whilst the incidence of sepsis in general is declining. The classifications of UTIs partially differ between clinical and regulatory claims. Experience has also been gained over the last few years to define the appropriate endpoints that are used in clinical studies. Above all, patient-centered evaluation strategies of the endpoints were developed, in order to be able to identify the advantages of new antibiotics compared to traditional antibiotics. The development of new antibiotics for UTIs is essential, since multidrug-resistant enterobacteria, which belong to the typical bacterial spectrum of UTIs, are frequently associated with mortality from infections. In recent years, several new antibiotics/combinations that are particularly effective against multi-resistant gram-negative pathogens have been investigated for the treatment of UTIs.

Otitis externa maligna con diseminación hematógena de Pseudomonas aeruginosa resistente a carbapenémicos

Pseudomonas aeruginosa en una bacteria Gram negativa no fermentadora que produce diversos tipos de infecciones severas en inmunocompetentes e inmunodeprimidos. Una de estas infecciones es la otitis externa maligna, la cual se presenta principalmente en personas con diabetes mellitus y puede tener una evolución tórpida cursando con osteomielitis de base de cráneo y parálisis de nervios craneales. El tratamiento es individualizado y principalmente conservador con antibioticoterapia guiada por cultivo. La bacteria aislada en la mayoría de los casos reportados es sensible a los antibióticos anti-pseudomónicos. Reportamos un caso de presentación inusual de otitis externa maligna por Pseudomonas aeruginosa resistente a carbapenémicos con evidencia sugerente de compromiso bilateral y en el cual se aisló al mismo germen en urocultivo y hemocultivos, lo que indicaría una diseminación hematógena del microorganismo.

Pseudomonas aeruginosa is a non-fermenting Gram-negative bacterium that produces several types of severe infections in immunocompetent and immunosuppressed patients. One of these infections is malignant otitis externa, which occurs mainly in people with diabetes mellitus and can have a torpid evolution coursing with osteomyelitis of skull base and cranial nerve palsies. Treatment is individualized and mainly conservative with culture-guided antibiotic therapy, with isolated pseudomonas being sensitive to anti-pseudomonal antibiotics in the majority of reported cases. We report a case of unusual presentation of malignant otitis externa caused by Pseudomonas aeruginosa resistant to carbapenems with suggestive evidence of bilateral involvement and in which the same germ was isolated in urine and blood cultures, which would indicate hematogenous dissemination of the microorganism.