An outbreak of severe or lethal infections by a multidrug-resistant Acinetobacter baumannii ST126 strain carrying a plasmid with blaNDM-1 and blaOXA-58 carbapenemases.

Acinetobacter baumannii poses a significant health threat because of its frequent implications in hospital outbreaks and multidrug resistance (MDR). Here, we studied four A. baumannii isolates recovered during a hospital outbreak of severe or fatal cases to elucidate their diversity and factors contributing to their increased virulence and antibiotic resistance. The isolates were identified using MALDI-ToF and characterized using comparative genomics, PCR, and antimicrobial susceptibility tests. They were classified as ST126 and exhibited fewer than five chromosomal single-nucleotide variants and the same extrachromosomal content, indicating that they are a single strain (A. baumannii AB01). A. baumannii AB01 showed an MDR phenotype that could be linked to the carriage of parC and gyrA mutations, efflux transporters, aminoglycoside resistance genes, a class C beta-lactamase, and three carbapenemases, some of which are encoded on a 72 kb plasmid. ST126 is infrequent and has not been reported in Latin America, and our genomic data indicate a plausible origin for A. baumannii AB01 within the Pan Pacific region.

Early Candida colonisation impact on patients and healthcare professionals in an intensive care unit.

OBJECTIVES: Candida spp. is an opportunistic pathogen that causes superficial and invasive infections with nosocomial outbreaks without strict hygiene protocols. Herein, we assessed oral colonisation by Candida spp. in 209 Intensive Care Unit (ICU) patients between July 2021 and April 2022, conducting clinical, epidemiological, and microbiological characterisation of those developing oral or invasive candidiasis. METHODS: Initial oral swabs were collected within 24 h of admission in the ICU, followed by collections on Days 2, 4, 6 and 8. Swabs from denture-wearing patients, abiotic surfaces, healthcare professionals' hands, and retroauricular regions were also obtained. Recovered yeasts and filamentous fungi were identified using MALDI-TOF MS and morphological characteristics, respectively. Genetic similarity of Candida spp. isolates was evaluated using Amplified fragment length polymorphism (AFLP), and the antifungal susceptibility profile was determined by broth microdilution. RESULTS: In the study, 64.11% of patients were orally colonised by Candida spp. Of these, 80.59% were colonised within the first 24 h. Oral colonisation also occurred on subsequent days: 50%/Day 2, 26.92%/Day 4, and 11.53%/Days 6 and 8. Of the patients, 8.61% had oral candidiasis, mainly pseudomembranous. Among orally colonised patients, 2.23% developed invasive candidiasis. Besides, 89.47% of healthcare professionals evaluated were colonised. MALDI-TOF MS identified different yeast species, and C. albicans (45.34%), C. tropicalis (15.7%), and C. parapsilosis sensu stricto (9.88%) were the most prevalent. AFLP analysis indicated a high genetic correlation (≥97%) between C. parapsilosis sensu stricto isolates from patients and professionals. Three resistant C. albicans isolates were also found. CONCLUSION: This study reported a diversity of yeast and filamentous fungi species in ICU patients and highlighted early Candida spp. colonisation risks for invasive candidiasis, as well as the potential horizontal transmission in the nosocomial setting, emphasising the need for effective infection control measures.

Clinical and microbiological characteristics of a hospital outbreak of Candida auris in a referral hospital in Lima, Peru.

BACKGROUND: Candida auris, a multidrug-resistant fungal pathogen, has received considerable attention owing to its recent surge, especially in South America, which coincides with the ongoing global COVID-19 pandemic. Understanding the clinical and microbiological characteristics of outbreaks is crucial for their effective management and control. OBJECTIVE: This retrospective observational study aimed to characterize a C. auris outbreak at a Peruvian referral hospital between January 2021 and July 2023. METHODS: Data were collected from hospitalized patients with positive C. auris culture results. Microbiological data and antifungal susceptibility test results were analysed. Additionally, infection prevention and control measures have been described. Statistical analysis was used to compare the characteristics between the infected and colonized patients. RESULTS: Thirty-three patients were identified, mostly male (66.7%), with a median age of 53 years. Among them, 18 (54.5%) were colonized, and 15 (45.5%) were infected. Fungemia was the predominant presentation (80%), with notable cases of fungemia in tuberculosis patients with long-stay devices for parenteral anti-tuberculosis therapy. Seventy-five percent of the isolates exhibited fluconazole resistance. Echinocandins were the primary treatment, preventing fungemia recurrence within 30 days. Infected patients had significantly longer hospital stays than colonized patients (100 vs. 45 days; p = .023). Hospital mortality rates were 46.7% and 25% in the infected and fungemia patients, respectively. Simultaneous outbreaks of multidrug-resistant bacteria were documented. CONCLUSIONS: This study underscores the severity of a C. auris outbreak at a referral hospital in Peru, highlighting its significant impact on patient outcomes and healthcare resources. The high prevalence of fluconazole-resistant isolates, leading to prolonged hospital stay and high mortality rates, particularly in cases of fungemia, underscores the critical need for effective infection prevention and control strategies.

Gastrointestinal endoscopy 30-day-associated bacteremia: Nonoutbreak 5-year review in an inner-city, tertiary-care hospital.

BACKGROUND: Gastrointestinal endoscopic procedures (GIEP's) are an essential part of patient care both diagnostically and therapeutically. Post-GIEP infections may be higher than previously reported and may not have been accurately captured in the past. The aim of this study was to determine the incidence and associated factors of bacteremia associated with GIEP's. METHODS: This is retrospective study of GIEPs performed over a five-year period (2018-2022) at an academic medical center. Electronic health records (EHR) identified GIEPs and positive blood cultures within 30 days of procedure. Statistical analysis was performed using non-parametric testing to compare variables due to the small number of positive blood cultures. RESULTS: EHR identified 18,986 GIEP's and 52 true and unique bacteremia out of 17,093 blood cultures during the five-year study period. The highest rate of positive blood culture of 2.84% (18/ 634) was associated with ERCP and the lowest 0.08% (7/ 9029) was associated with colonoscopy. DISCUSSION: Our study showed a reflection of the endemic rate of bacteremia post GIEP's. Our study cannot differentiate endogenous infection versus contaminated (exogenous) endoscopes. ERCP procedures are disproportionately associated with higher incidence of bacteremia. CONCLUSIONS: Clinical surveillance in non-outbreak settings is essential for estimating GIEP related infections. It should be combined with endoscopic reprocessing audits for appropriate prevention of GIEP associated infections.

Analysis of factors associated with mortality due to sepsis resulting from device-related infections.

INTRODUCTION: Health care-associated infections (HAIs) contribute to morbidity and mortality and to the dissemination of multidrug-resistant organisms. Children admitted to the intensive care unit undergo invasive procedures that increase their risk of developing HAIs and sepsis. The aim of the study was to analyse factors associated with mortality due to sepsis arising from HAIs. PATIENTS AND METHODS: We conducted a case-control study in a 7-bed multipurpose paediatric intensive care unit in a tertiary care teaching hospital. The sample consisted of 90 children admitted between January 2014 and December 2018. The case group consisted of patients who died from sepsis associated with the main health care-associated infections; the control group consisted of patients who survived sepsis associated with the same infections. RESULTS: Death was associated with age less than or equal to 12 months, presence of comorbidity, congenital disease, recurrent ventilator-associated pneumonia and septic shock. In the multiple regression analysis, heart disease (OR, 12.48; CI 2.55-60.93; P = .002), infection by carbapenem-resistant bacteria (OR, 31.51; CI 4.01-247.25; P = .001), cancer (OR, 58.23; CI 4.54-746.27; P = .002), and treatment with adrenaline (OR, 13.14; CI 1.35-128.02; P = .003) continued to be significantly associated with death. CONCLUSIONS: Hospital sepsis secondary to carbapenem-resistant bacteria contributed to a high mortality rate in this cohort. Children with heart disease or neoplasia or who needed vasopressor drugs had poorer outcomes.

Stenotrophomonas maltophilia outbreak in a university hospital: epidemiological investigation and literature review of an emerging healthcare-associated infection.

Stenotrophomonas maltophilia was considered to be a low-virulence organism. But it has emerged as a prominent opportunistic pathogen in patients with certain risk factors. This study aimed to describe an outbreak experienced in our hospital with all dynamics while evaluating previous S. maltophilia outbreak reports. S. maltophilia isolates were obtained from a university hospital in Türkiye in a seven-months period. Antimicrobial resistance, type of infections, predisposing factors of infected patients, antibiotic therapy, outcome of infections, and outbreak source were investigated. Also, S. maltophilia outbreaks in the literature were reviewed. In the 12 months prior to the outbreak, prevalence rate of clinical samples including S. maltophilia was 7/1,000 patient per day, opposed to 113/1,000 patient per day during the outbreak. Although a large number of cases were observed in a short seven-month period, a source of contamination could not be detected. Stable mortality rates (or remaining close to the average) during outbreaks can be attributed to the careful attention paid by laboratory and clinic physicians during procedures. S. maltophilia has potential to spread outbreaks and infect patients in operating rooms and intensive care units during invasive procedures.

Whole-genome sequencing analysis of multidrug-resistant Serratia marcescens isolates in an intensive care unit in Brazil.

INTRODUCTION: Serratia marcescens is an opportunistic pathogen found ubiquitously in the environment and associated with a wide range of nosocomial infections. This multidrug-resistant bacterium has been a cause of concern for hospitals and healthcare facilities due to its ability to spread rapidly and cause outbreaks. Next generation sequencing genotyping of bacterial isolates has proven to be a valuable tool for tracking the spread and transmission of nosocomial infections. This has allowed for the identification of outbreaks and transmission chains, as well as determining whether cases are due to endogenous or exogenous sources. Evidence of nosocomial transmission has been gathered through genotyping methods. The aim of this study was to investigate the genetic diversity of carbapenemase-producing S. marcescens in an outbreak at a public hospital in Cuiaba, MT, Brazil. METHODOLOGY: Ten isolates of S. marcenses were sequenced and antibiotic resistance profiles analyzed over 12 days. RESULTS: The isolates were clonal and multidrug resistant. Gentamycin and tigecycline had sensitivity in 90% and 80% isolates, respectively. Genomic analysis identified several genes that encode ß-lactamases, aminoglycoside-modifying enzymes, efflux pumps, and other virulence factors. CONCLUSIONS: Systematic surveillance is crucial in monitoring the evolution of S. marcescens genotypes, as it can lead to early detection and prevention of outbreaks.

Genomic and phenotypic studies among Clostridioides difficile isolates show a high prevalence of clade 2 and great diversity in clinical isolates from Mexican adults and children with healthcare-associated diarrhea.

Clostridioides difficile (C. difficile) is widely distributed in the intestinal tract of humans, animals, and in the environment. It is the most common cause of diarrhea associated with the use of antimicrobials in humans and among the most common healthcare-associated infections worldwide. Its pathogenesis is mainly due to the production of toxin A (TcdA), toxin B (TcdB), and a binary toxin (CDT), whose genetic variants may be associated with disease severity. We studied genetic diversity in 39 C. difficile isolates from adults and children attended at two Mexican hospitals, using different gene and genome typing methods and investigated their association with in vitro expression of toxins. Whole-genome sequencing in 39 toxigenic C. difficile isolates were used for multilocus sequence typing, tcdA, and tcdB typing sequence type, and phylogenetic analysis. Strains were grown in broth media, and expression of toxin genes was measured by real-time PCR and cytotoxicity in cell-culture assays. Clustering of strains by genome-wide phylogeny matched clade classification, forming different subclusters within each clade. The toxin profile tcdA+/tcdB+/cdt+ and clade 2/ST1 were the most prevalent among isolates from children and adults. Isolates presented two TcdA and three TcdB subtypes, of which TcdA2 and TcdB2 were more prevalent. Prevalent clades and toxin subtypes in strains from children differed from those in adult strains. Toxin gene expression or cytotoxicity was not associated with genotyping or toxin subtypes. In conclusion, genomic and phenotypic analysis shows high diversity among C. difficile isolates from patients with healthcare-associated diarrhea. IMPORTANCE: Clostridioides difficile is a toxin-producing bacterial pathogen recognized as the most common cause of diarrhea acquired primarily in healthcare settings. This bacterial species is diverse; its global population has been divided into five different clades using multilocus sequence typing, and strains may express different toxin subtypes that may be related to the clades and, importantly, to the severity and progression of disease. Genotyping of children strains differed from adults suggesting toxins might present a reduced toxicity. We studied extensively cytotoxicity, expression of toxins, whole genome phylogeny, and toxin typing in clinical C. difficile isolates. Most isolates presented a tcdA+/ tcdB+/cdt+ pattern, with high diversity in cytotoxicity and clade 2/ST1 was the most prevalent. However, they all had the same TcdA2/TcdB2 toxin subtype. Advances in genomics and bioinformatics tools offer the opportunity to understand the virulence of C. difficile better and find markers for better clinical use.

Impacto de la implementación de la estrategia multimodal de la OMS para mejorar la higiene de manos en una Unidad de Cuidados Intensivos / Impact on implementation of multimodal of World Health Organization strategies to improve hand hygiene in an Intensive Care Unit

INTRODUCCIÓN: La higiene de manos (HM) es la principal medida para disminuir las IAAS, las que en las Unidades de Cuidados Intensivos (UCI) presentan una alta prevalencia. En Chile no existe información sobre el impacto de la estrategia multimodal de la OMS para la HM en adultos. El objetivo fue evaluar el impacto de la implementación de la estrategia en una UPC. METODOLOGÍA: Estudio longitudinal con evaluación pre y post-intervención, entre los años 2018 y 2021, en la UCI del Hospital del Trabajador (HT), Santiago, Chile. La implementación se evaluó con pautas de cumplimiento de HM, consumo de jabón y productos en base alcohólica (PBA). El impacto se midió con las tasas de neumonía asociada a ventilación mecánica (NAVM), infecciones del torrente sanguíneo asociadas a CVC (ITS- CVC) y del tracto urinario por CUP (ITU-CUP), y la incidencia anual de dermatitis. RESULTADOS: El cumplimiento de pautas aumentó de 91 a 96% (p < 0,05). El consumo total de productos para la HM aumentó de 0,17 a 0,31 L/día/cama y de PBA en 10%. Las tasas de IAAS pre y post-intervención fueron para NAVM de 10,3 y 8,4; ITS-CVC de 0,8 y 1,5 e ITU-CUP de 4,2 y 5,3 por 1.000 días de exposición. La incidencia anual de dermatitis disminuyó en 30% (p < 0,05). CONCLUSIONES: La implementación de la estrategia multimodal se asoció a una disminución de las tasas de NAVM y de dermatitis en la UCI del HT.

INTRODUCTION: Hand hygiene is the main measure to decrease infections related to healthcare and the Intensive Care Unit has a high prevalence. In Chile there aren't reports about the impact of the World Health Organization multimodal hand hygiene improvement strategy. AIM: To assess the implementation impact of this strategy at the ICU. METHODOLOGY: Longitudinal study with pre- and postintervention evaluation during the years 2018-2021 at ICU. The implementation was assessed against hand hygiene compliance guidelines, soap consumption and alcohol-based products. The impact was evaluated with the rates of ventilator-associated pneumonia (VAP), catheter related bloodstream infection (CRBSI) and catheter associated urinary tract infection (CAUTI) and the annual dermatitis incidence. RESULTS: The guidelines compliance increased from 91% to 96% (p < 0.05). The total product consumption increased from 0.17 to 0.31 Liters/day/bed. The use of alcohol-based products increased by 10%. HAI rates pre- and post-intervention were for VAP 10.3 and 8.4, CRBSI 0.8 and 1.5 and CAUTI 4.2 and 5.3. The annual dermatitis incidence decreased by 30.8% (p < 0.05). CONCLUSIONS: The strategy implementation benefited the decrease of VAP and the dermatitis prevention in ICU.

Molecular characterization and descriptive analysis of carbapenemase-producing Gram-negative rod infections in Bogota, Colombia.

In this study, the genetic differences and clinical impact of the carbapenemase-encoding genes among the community and healthcare-acquired infections were assessed. This retrospective, multicenter cohort study was conducted in Colombia and included patients infected with carbapenem-resistant Gram-negative rods between 2017 and 2021. Carbapenem resistance was identified by Vitek, and carbapenemase-encoding genes were identified by whole-genome sequencing (WGS) to classify the alleles and sequence types (STs). Descriptive statistics were used to determine the association of any pathogen or gene with clinical outcomes. A total of 248 patients were included, of which only 0.8% (2/248) had community-acquired infections. Regarding the identified bacteria, the most prevalent pathogens were Pseudomonas aeruginosa and Klebsiella pneumoniae. In the WGS analysis, 228 isolates passed all the quality criteria and were analyzed. The principal carbapenemase-encoding gene was blaKPC, specifically blaKPC-2 [38.6% (88/228)] and blaKPC-3 [36.4% (83/228)]. These were frequently detected in co-concurrence with blaVIM-2 and blaNDM-1 in healthcare-acquired infections. Notably, the only identified allele among community-acquired infections was blaKPC-3 [50.0% (1/2)]. In reference to the STs, 78 were identified, of which Pseudomonas aeruginosa ST111 was mainly related to blaKPC-3. Klebsiella pneumoniae ST512, ST258, ST14, and ST1082 were exclusively associated with blaKPC-3. Finally, no particular carbapenemase-encoding gene was associated with worse clinical outcomes. The most identified genes in carbapenemase-producing Gram-negative rods were blaKPC-2 and blaKPC-3, both related to gene co-occurrence and diverse STs in the healthcare environment. Patients had several systemic complications and poor clinical outcomes that were not associated with a particular gene.IMPORTANCEAntimicrobial resistance is a pandemic and a worldwide public health problem, especially carbapenem resistance in low- and middle-income countries. Limited data regarding the molecular characteristics and clinical outcomes of patients infected with these bacteria are available. Thus, our study described the carbapenemase-encoding genes among community- and healthcare-acquired infections. Notably, the co-occurrence of carbapenemase-encoding genes was frequently identified. We also found 78 distinct sequence types, of which two were novel Pseudomonas aeruginosa, which could represent challenges in treating these infections. Our study shows that in low and middle-income countries, such as Colombia, the burden of carbapenem resistance in Gram-negative rods is a concern for public health, and regardless of the allele, these infections are associated with poor clinical outcomes. Thus, studies assessing local epidemiology, prevention strategies (including trials), and underpinning genetic mechanisms are urgently needed, especially in low and middle-income countries.

Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil.

BACKGROUND: Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact. METHODS: We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled. FINDINGS: From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%. INTERPRETATION: A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.

Effect of COVID-19 on infections associated with medical devices in critical care.

OBJECTIVES: This study explores the hypothesis that COVID-19 patients are at a heightened risk of healthcare-associated infections (HAIs) associated with medical device usage compared to non-COVID-19 patients. Our primary objective was to investigate the correlation between COVID-19 infection in ICU patients and subsequent HAIs following invasive medical device insertion. Additionally, we aim to assess the impact of SARS-CoV-2 infection on onset times concerning specific microorganisms and the type of medical device, providing valuable insights into this intricate relationship in intensive care settings. METHODOLOGY: A retrospective cohort study was conducted using ICU patient records at our hospital from 2020 to 2022. This investigation entailed evaluating the timing of HAIs while distinguishing between patients with and without SARS-CoV-2 infection. We identified and analyzed the type of isolation and infection attributed to the medical device while controlling for ICU duration and ventilator days using Cox regression. RESULTS: Our study included 127 patients without SARS-CoV-2 infection and 140 patients with SARS-CoV-2 infection. The findings indicated a higher incidence of HAI caused by various microorganisms associated with any medical device in patients with SARS-CoV-2 (HR = 6.86; 95% CI-95%: 3.26-14.43; p < 0.01). After adjusting for ICU duration and ventilator days, a heightened frequency of HAIs persisted in SARS-CoV-2-infected individuals. However, a detailed examination of HAIs revealed that only ventilation-associated pneumonia (VAP) displayed a significant association (HR = 6.69; 95% CI: 2.59-17.31; p < 0.01). A statistically significant correlation between SARS-CoV-2 infection and the isolation of S. aureus was also observed (p = 0.034). The prevalence of S. aureus infection was notably higher in patients with SARS-CoV-2 (RR = 8.080; 95% CI: 1.052-62.068; p < 0.01). CONCLUSIONS: The frequency of pathogen isolates in invasive medical devices exhibited an association with SARS-CoV-2 infection. Critically ill patients with SARS-CoV-2 are more prone to developing early-onset VAP than those without SARS-CoV-2 infection.

Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity.

Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.

Clinical and microbiological profile of health care-associated infections in a tertiary hospital: Comparison between a cohort of hospitalized patients during prepandemic and COVID-19 pandemic periods.

BACKGROUND: During the COVID-19 pandemic, health service practices underwent significant changes, impacting the occurrence of health care-associated infections (HAIs). This study presents the epidemiology of bacterial infections and compares clinical data on nosocomial infections in hospitalized patients before and during the pandemic. METHODS: A unicentric, observational, retrospective cohort study was conducted with descriptive analyses on the microorganism identification and resistance profile. Patient's clinical data who had hospital-acquired infection (HAI), during their hospitalization in a tertiary hospital before and during the COVID-19 pandemic was compared by descriptive and inferential analyses. RESULTS: A total of 1,581 bacteria were isolated from 1,183 hospitalized patients. Among patients coinfected with COVID-19, there was a statistically significant increase in HAI-related deaths (P < .001) and HAI caused by multidrug-resistant organisms (P < .001), mainly by Acinetobacter baumannii and Staphylococcus aureus. A higher odds ratio of HAI-related deaths compared to the prepandemic period was observed (odds ratio 6.98 [95% confidence interval 3.97-12.64]). CONCLUSIONS: The higher incidence of multidrug-resistant bacteria and increased deaths due to HAI, especially in patients with COVID-19 coinfection, might be related to various factors such as increased workload, broad-spectrum antibiotic use, and limited resources. The pandemic has changed the profile of circulating bacteria and antimicrobial resistance. Prevention strategies should be considered to reduce the impact of these infections.

Hospital-acquired infections surveillance: The machine-learning algorithm mirrors National Healthcare Safety Network definitions.

BACKGROUND: Surveillance of hospital-acquired infections (HAIs) is the foundation of infection control. Machine learning (ML) has been demonstrated to be a valuable tool for HAI surveillance. We compared manual surveillance with a supervised, semiautomated, ML method, and we explored the types of infection and features of importance depicted by the model. METHODS: From July 2021 to December 2021, a semiautomated surveillance method based on the ML random forest algorithm, was implemented in a Brazilian hospital. Inpatient records were independently manually searched by the local team, and a panel of independent experts reviewed the ML semiautomated results for confirmation of HAI. RESULTS: Among 6,296 patients, manual surveillance classified 183 HAI cases (2.9%), and a semiautomated method found 299 HAI cases (4.7%). The semiautomated method added 77 respiratory infections, which comprised 93.9% of the additional HAIs. The ML model considered 447 features for HAI classification. Among them, 148 features (33.1%) were related to infection signs and symptoms; 101 (22.6%) were related to patient severity status, 51 features (11.4%) were related to bacterial laboratory results; 40 features (8.9%) were related to invasive procedures; 34 (7.6%) were related to antibiotic use; and 31 features (6.9%) were related to patient comorbidities. Among these 447 features, 229 (51.2%) were similar to those proposed by NHSN as criteria for HAI classification. CONCLUSION: The ML algorithm, which included most NHSN criteria and >200 features, augmented the human capacity for HAI classification. Well-documented algorithm performances may facilitate the incorporation of AI tools in clinical or epidemiological practice and overcome the drawbacks of traditional HAI surveillance.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM: To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS: A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS: The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION: Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

La amenaza silenciosa de las resistencias bacterianas / The silent threat of bacterial resistance

Las resistencias bacterianas a antimicrobianos representan uno de los principales problemas en la actualidad, encontrándose dentro de las principales causas de muerte en todo el mundo. Latinoamérica y Argentina, lejos de ser una excepción,presentan incidencias crecientes de infecciones por gérmenes resistentes. Cada día, se conocen mejor los mecanismos de resistencia que presentan los bacilos gram negativos y algunos cocos positivos. El problema no surge sólo por el sobreuso de antimicrobianos en la medicina clínica. Su sobreutilización para maximizar los beneficios productivos en la pesca, la ganadería y la agricultura contribuyen a esta situación. Desde la perspectiva de la atención primaria de la salud,consideramos fundamental conocer todos los aspectos que forman parte de esta problemática para intentar mitigar el daño que las resistencias bacterianas generan a nivel global. Argentina se transformó en el primer país de la región y del continente en contar con una ley para prevenir y controlar la resistencia a los Antimicrobianos. Consideramos de vital importancia que se fomenten más y mejores políticas sanitarias de orden público para enfrentar este creciente desafío. (AU)

Nowadays, bacterial resistance to antimicrobials is one of the main problems, being one of the leading causes of death worldwide. Latin America and Argentina, far from being an exception, have an increasing incidence of infections by resistant germs. Every day, the resistance mechanisms of gram-negative bacilli and some positive cocci are better known. The problem does not arise only because of the overuse of antimicrobials in clinical medicine. Its overuse to maximize productive benefits in fishing, livestock, and agriculture also contributes to this issue. From the perspective of primary health care,it is essential to know all the aspects of this problem to mitigate the damage that bacterial resistance generates at a global level. Argentina became the first country in the region and the continent to have a law to prevent and control antimicrobial resistance. We consider it vitally important that more and better public health policies are promoted to face this growing challenge. (AU)

Antimicrobial resistance and epidemic clustering of late-onset neonatal infections in a Brazilian intensive care unit.

Nosocomial infections in the neonatal intensive care unit (NICU) tend to cluster and multidrug-resistant (MDR) pathogens are rising in developing countries. We did a retrospective cohort study of neonates admitted to a NICU in Brazil with late-onset neonatal sepsis (LOS) confirmed by blood culture from October 2012 to December 2016 and from July 2018 to December 2021. We defined a cluster of infection when at least two cases of LOS occurred within two different time intervals: 15 and 30 days with the same pathogen in different patients. A random amplified polymorphic DNA (RAPD) was performed from samples from one of these clusters. A logistic regression model was applied having death as the outcome and the infection with an MDR pathogen as the exposure of interest. There were 987 blood cultures from 754 neonates, 621 (63%) were gram-positive cocci, 264 (30%) were gram-negative rods and 72 (7%) fungi. A third of Enterobacterales were resistant to cefepime and a third of non-fermenting glucose rods were resistant to carbapenems. There were 100 or 104 clusters of infection in the 15- or 30-day interval, respectively. A RAPD analysis from an outbreak of MDR Acinetobacter baumannii showed that all five samples belonged to a single clone. An infection with an MDR pathogen was associated with death (OR 1.82, 95% CI 1.03-3.21). In conclusion, clusters of infections in a Brazilian NICU are a frequent phenomenon as seen elsewhere. They suggest cross-transmission of pathogens with increasing antimicrobial resistance and should prompt intensified surveillance and infection control measures.

Case Report: Outbreak of Nosocomial Myiasis by Cochliomyia macellaria (Diptera, Calliphoridae) in a Hospital in Colima, Mexico.

Myiasis in humans is a disease caused by larvae of various fly families. It mainly occurs in communities with poor sanitation and low socioeconomic status. Meanwhile intrahospital or nosocomial myiasis represents a rare phenomenon but is of relevance to public health. Here, we report an outbreak of myiasis caused by Cochliomyia macellaria in five patients hospitalized for several diseases at the Service of Internal Medicine of the Hospital Regional Universitario de Colima, Mexico during June and July 2021. Three patients were males and two were females, aged 37 to 83 years. All were affected by myiasis caused by larvae of the fly C. macellaria. Three patients underwent invasive mechanical ventilation; one had cutaneous basal cell cancer and one had advanced diabetic foot. This event occurred after 4 days of hospitalization and in the same hospital pavilion. Two patients died, and the others were discharged after treatment with antibiotics and ivermectin. We believe that this nosocomial cluster represents a more frequent phenomenon than reported in tropical countries, where authorities should pay attention to its timely detection, especially in vulnerable populations.

Metabarcoding approach to identify bacterial community profiling related to nosocomial infection and bacterial trafficking-routes in hospital environments.

Nosocomial infections (NIs) appear in patients under medical care in the hospital. The surveillance of the bacterial communities employing high-resolution 16S rRNA profiling, known as metabarcoding, represents a reliable method to establish factors that may influence the composition of the bacterial population during NIs. The present study aimed to utilize high-resolution 16S rRNA profiling to identify high bacterial diversity by analyzing 11 inside and 10 outside environments from the General Hospital of Ribeirão Preto Medical School, Brazil. Our results identified a high bacterial diversity, and among these, the most abundant bacterial genera linked to NIs were Cutibacterium, Streptococcus, Staphylococcus, and Corynebacterium. A Acinetobacter was detected in cafeterias, bus stops, and adult and pediatric intensive care units (ICUs). Data suggest an association between transport and alimentation areas proximal to the hospital ICU environment. Interestingly, the correlation and clusterization analysis showed the potential of the external areas to directly influence the ICU pediatric department microbial community, including the outpatient's clinic, visitor halls, patient reception, and the closest cafeterias. Our results demonstrate that high-resolution 16S rRNA profiling is a robust and reliable tool for bacterial genomic surveillance. In addition, the metabarcoding approach might help elaborate decontamination policies, and consequently reduce NIs.