The Clinical and Molecular Epidemiology of Noncarbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae: A Case-Case-Control Matched Analysis.

BACKGROUND: Risk factors and outcomes associated with carbapenem-resistant Enterobacteriaceae (CRE) acquisitions are derived primarily from cohorts consisting of carbapenemase-producing (CP) strains. Worldwide epidemiology of non-CP-CRE is evolving, but controlled epidemiological analyses are lacking. METHODS: A matched case-case-control investigation was conducted at Shamir (Assaf Harofeh) Medical Center, Israel, on November 2014-December 2016. Noncarbapenemase-producing CRE (as defined by the US Clinical and Laboratory Standards Institute Standards) carriers were matched to patients with non-CRE Enterobacterales and to uninfected controls (1:1:1 ratio). Matched and nonmatched multivariable regression models were constructed to analyze predictors for acquisition and the independent impact of carriage on multiple outcomes, respectively. Representative isolates were whole genome sequenced and analyzed for resistome and phylogeny. RESULTS: Noncarbapenemase-producing CRE carriers (n = 109) were matched to the 2 comparative groups (overall n = 327). Recent exposure to antibiotics (but not specifically to carbapenems), prior intensive care unit admission, and chronic skin ulcers were all independent predictors for non-CP-CRE acquisition. Acquisitions were almost exclusively associated with asymptomatic carriage (n = 104), and despite strong associations per univariable analyses, none were independently associated with worse outcomes. Genomic analyses of 13 representative isolates revealed polyclonality, confirmed the absence of carbapenemases, but confirmed the coexistence of multiple other genes contributing to carbapenem-resistance phenotype (multiple beta-lactamases and efflux pumps). CONCLUSIONS: Noncarbapenemase-producing CRE acquisitions are primarily associated with asymptomatic carriage, specifically among prone populations with extensive recent exposures to antibiotics. The prevalent mode of acquisition is "emergence of resistance" (not "patient-to-patient transmission"), and therefore the role of stewardship interventions in reducing the spread of these therapeutically challenging pathogens should be further explored.

The yield of respiratory viruses detection testing is age-dependent in children with acute otitis media.

BACKGROUND: Studies of nasopharyngeal secretions serve as reliable surrogate to evaluate the involvement of viruses in acute otitis media (AOM) and upper/lower respiratory tract infections (URIs/LRIs). We explored nasopharyngeal viral studies from children with uncomplicated AOM and examined their cost-effectiveness in relation to their age. METHODS: We identified children aged 0-6 years admitted to our pediatrics department in a university-affiliated, secondary hospital with uncomplicated AOM and concurrent URI/LRI between 2012 and 2017, during October-April, when viral studies are performed. Studies were performed either using antigen detection tests, for respiratory syncytial virus (RSV) and influenza A/B (2012-2016) and for a variety of other common respiratory viruses, utilizing multiplex polymerase chain reaction assays (2017). RESULTS: A total of 249 children were included (median age: 15 months). In 88 (35%) children, viral studies were positive, most of them in children ⩽24 months (78, 89%). RSV was positive in 52 (59%) children, followed by influenza A and B, in 11 (13%) and 5 (6%) children, respectively. First year switch to a molecular assay, 4.5-fold more expensive, resulted in a statistically significant higher yield: 69% positive results in ⩽24 months, and 66% in those aged ⩽12 months (p < 0.05). In those ⩽24 months, US$23 and US$95 were spent for one positive test in the antigen detection years and the polymerase chain reaction year, respectively, whereas in those >24 months, US$83 and US$878 were invested for one positive test in the same year, respectively. CONCLUSION: In cost-effectiveness terms, the greatest benefit of nasopharyngeal studies was highest in children ⩽24 months.

Pediatric neck abscesses: No increase in methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Recent studies from Western countries showed an increased incidence rate of methicillin-resistant Staphylococcus aureus (MRSA) isolated from pediatric neck abscesses cultures. We sought to examine the microbiology and antibiotic susceptibility of such samples over a 10-year period, and particularly of Staphylococcus aureus (SA), in order to determine whether a similar trend exists in our institution. METHODS: A retrospective chart review of children ≤18 years that underwent needle aspiration or surgical drainage of neck abscesses, including suppurative lymphadenitis, retropharyngeal abscesses, and parapharyngeal abscesses was conducted between 1/1/06-31/12/15. RESULTS: Sixty-two children were identified with a male predominance (34, 55%). The median age was 2 years. There were 37 (60%) suppurative lymphadenitis, 15 (24%) parapharyngeal abscess, and 10 (16%) retropharyngeal abscess cases. Twenty-nine (47%) children received antibiotic treatment prior to admission, most commonly ß-lactam agents. Of them, 15 (52%) had positive cultures, including 7 (47%) with SA. On admission, 45 (73%) children had already received amoxicillin-clavulanate. Of those who did not improve, 16 (26%) received ceftriaxone and clindamycin. Twenty-one (38%) cultures were negative. The most common isolated bacteria were SA in 13 (24%), Streptococcus pyogenes in 7 (13%), and Streptococcus viridians group in 9 (16%). Of the SA isolates, there was only 1 (8%) case of MRSA; however, there were 4 (31%) clindamycin-resistant SA isolates. CONCLUSION: Unlike previously published data, there was no increase in MRSA incidence at our institution. However, the high prevalence of clindamycin-resistant SA was in line with previous reports. These findings should be considered when starting empirical therapy in pediatric neck abscesses.

Decrease in Pneumococcal Otitis Media Cultures With Concomitant Increased Antibiotic Susceptibility in the Pneumococcal Conjugate Vaccines Era.

OBJECTIVE: To study the change in the incidence and antibiotic susceptibility patterns of Streptococcus pneumoniae (Spn) in cultures obtained from children with otitis media (OM) during the pneumococcal conjugate vaccines (PCVs) era. STUDY DESIGN: Retrospective. SETTING: Secondary medical care center. PATIENTS: Children less than 8 years who presented with OM and had positive pneumococcal cultures during January 1, 2007 to December 12, 2014 were identified. Data recorded included demographics, preadmission antibiotics, culture source, and antibiotic susceptibility tests. We compared the pre-PCV years (2007-2008) with the transition years (2009-2011) and the post-PCV13 years (2012-2014). INTERVENTIONS: PCV7 (2009), PCV13 (2010), therapeutic. MAIN OUTCOME MEASURE(S): Annual rate of Spn cultures, antibiotic susceptibility patterns. RESULTS: We identified 134 children (76 boys, 57%) who contributed 162 pneumococcal cultures. There was a downward trend in the annual incidence rate of Spn cultures between the pre-PCV years, transition years, and post-PCV13 years: 11.12, 8.48, and 4.11/1000 hospitalized children/year, respectively (p = 0.08, p = 0.04). Had there been no interventions, and based on the 2007 to 2009 average, the observed over the expected Spn cultures ratio rates for 2010 to 2014 were 0.59, 0.45, 0.40, 0.40, and 0.25, respectively. In parallel, the susceptibility of Spn strains to four commonly tested antibiotics significantly increased from the pre-PCV years to the transition years and the post-PCV13 years. In each period, Spn strains were penicillin sensitive in 37, 51, and 100%; for erythromycin, 46, 71, and 82%; for trimethoprim/sulfamethoxazole, 32, 71, and 97%; and for ceftriaxone, 95, 96, and 100%, respectively. CONCLUSION: The introduction of PCVs significantly decreased the incidence rate of pneumococcal OM, and increased Spn susceptibility to common antibiotics.

First national surveillance of susceptibility of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp. to antimicrobials in Israel.

In this 1st national surveillance study, the susceptibility pattern of 1011 consecutive isolates of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. isolated from patients hospitalized in Israel hospitals, covering 62.3% of all general hospital beds in the country, was investigated. Proportion of susceptibilities (range among institutions, MIC(50)/MIC(90) in micrograms per milliliter) were to ertapenem 95.0% (88.8-100%, 0.19/0.75), imipenem 98.8% (88.8-100%, 0.25/0.38), meropenem 98.2% (90.0-100%, 0.06/0.19), piperacillin-tazobactam 59.1% (42.6-77.0%, 16/256), ciprofloxacin 17.2% (9.0-24.6%, 32/32), levofloxacin 17.8% (9.0-24.6%, 32/32), amikacin 74.5% (63.8-98.0%, 6/32), and gentamicin 19.3% (12.3-28.5%, 96/256). Coresistance, cross-resistance, and variability between institutions were high. Only carbapenems retain predicted activity against ESBL-producing E. coli and Klebsiella spp. across Israeli hospitals.