A fatal outbreak of neonatal sepsis caused by mcr-10-carrying Enterobacter kobei in a tertiary care hospital in Nepal.

BACKGROUND: Enterobacter kobei is an emerging cause of outbreak of nosocomial infections in neonatal intensive care units (NICUs). Between July and September 2016, a NICU in a tertiary care hospital of Nepal observed an abrupt increase in the number of neonatal sepsis cases caused by Enterobacter spp. infecting 11 out of 23 admitted neonates, five of whom died of an exacerbated sepsis. AIM: To confirm the suspected outbreak, identify environmental source of infection, and characterize genetic determinants of antimicrobial resistance (AMR) and virulence of the pathogen. METHODS: Whole-genome sequencing of all Enterobacter spp. isolated from blood cultures of septic neonates admitted to NICU between May 2016 and December 2017 was performed. Also, an environmental sampling was intensified from fortnightly to weekly during the outbreak. FINDINGS: The genomic analysis revealed that 10 out of 11 non-duplicated E. kobei isolated from neonatal blood cultures between July and September 2016 were clonal, confirming the outbreak. The isolates carried AMR genes including blaAmpC and mcr-10 conferring reduced susceptibility to carbapenem and colistin respectively. The environmental sampling, however, failed to isolate any Enterobacter spp. Reinforcement of aseptic protocols in invasive procedures, hand hygiene, environmental decontamination, fumigation, and secluded care of culture-positive cases successfully terminated the outbreak. CONCLUSION: Our study underscored the need to implement stringent infection control measures to prevent infection outbreaks. For the first time, we report the emergence of carbapenem and colistin non-susceptible E. kobei carrying mcr-10 gene as a cause of nosocomial neonatal sepsis in a NICU.

Handwashing Practices in Neonatal Intensive Care Unit, Paediatric Intensive Care Unit and Neonatal Nurseries in Patan Hospital.

BACKGROUND: Hand hygiene has been identified as the single most important factor in minimising hospital acquired infections. However, compliance of handwashing guidelines has remained low. The aim of this study was to study the handwashing practices in the Paediatric and Neonatal intensive care units and Neonatal nurseries in Patan Hospital, and secondly to re-evaluate the improvement on compliance of handwashing guidelines after intervention. METHODS: Pre-intervention study was conducted by covertly observing the handwashing practices by the healthcare workers. The healthcare workers were then shown the video demonstrating correct methods of handwashing as recommended by World health organization. The cycle was completed by discretely re-observing the handwashing practices following intervention. RESULTS: Sixty five samples were collected initially. Only 6 (9.2%) had completed all steps of handwashing correctly. Post- intervention, 51 samples were collected, out of which 35 (68.6%) had correctly completed all the steps. Following audio-visual demonstration, 100% correctly completed 8/10 steps of handwashing with soap and water. 8 (16%) failed to dry hands using a single use towel and 14 (28%) failed to turn off the tap using elbow. Post- intervention, 100% correctly completed 4/7 steps of handwashing using chlorhexidine. Four (15%) still failed to rub backs of fingers to opposite palm, eight (30%) failed to palm to palm with fingers interlaced, and rub thumb to opposite palm. CONCLUSIONS: Compliance in hand hygiene is low despite the known fact that it reduces nosocomial infections. However, a simple intervention like video demonstration can improve the compliance among healthcare workers.

Occurrence of Pharmaceuticals in Calgary's Wastewater and Related Surface Water.

The influents/effluents from Calgary's water resource recovery facilities and the surface water were analyzed for pharmaceuticals in the present study. The median concentrations in the effluents for the 15 targeted pharmaceuticals were within the range of 0.006 to 3.32 ppb. Although the wastewater treatment facilities were not designed to remove pharmaceuticals, this study indicates that the wastewater treatment processes are effective in removing some of the pharmaceuticals from the aqueous phase. The removal rate estimated can be 99.5% for caffeine, whereas little or no removal was observed for carbamazepine. Biodegradation, chemical degradation, and sorption could be some of the mechanisms responsible for the removal of pharmaceuticals. The drug residues in downstream surface water could be associated with incomplete removal of pharmaceuticals during the treatment process and may lead to concerns in terms of potential impacts on the aquatic ecosystem. However, this study does not indicate any immediate risks to the downstream aquatic environment.

Genome sequencing of an extended series of NDM-producing Klebsiella pneumoniae isolates from neonatal infections in a Nepali hospital characterizes the extent of community- versus hospital-associated transmission in an endemic setting.

NDM-producing Klebsiella pneumoniae strains represent major clinical and infection control challenges, particularly in resource-limited settings with high rates of antimicrobial resistance. Determining whether transmission occurs at a gene, plasmid, or bacterial strain level and within hospital and/or the community has implications for monitoring and controlling spread. Whole-genome sequencing (WGS) is the highest-resolution typing method available for transmission epidemiology. We sequenced carbapenem-resistant K. pneumoniae isolates from 26 individuals involved in several infection case clusters in a Nepali neonatal unit and 68 other clinical Gram-negative isolates from a similar time frame, using Illumina and PacBio technologies. Within-outbreak chromosomal and closed-plasmid structures were generated and used as data set-specific references. Three temporally separated case clusters were caused by a single NDM K. pneumoniae strain with a conserved set of four plasmids, one being a 304,526-bp plasmid carrying bla(NDM-1). The plasmids contained a large number of antimicrobial/heavy metal resistance and plasmid maintenance genes, which may have explained their persistence. No obvious environmental/human reservoir was found. There was no evidence of transmission of outbreak plasmids to other Gram-negative clinical isolates, although bla(NDM) variants were present in other isolates in different genetic contexts. WGS can effectively define complex antimicrobial resistance epidemiology. Wider sampling frames are required to contextualize outbreaks. Infection control may be effective in terminating outbreaks caused by particular strains, even in areas with widespread resistance, although this study could not demonstrate evidence supporting specific interventions. Larger, detailed studies are needed to characterize resistance genes, vectors, and host strains involved in disease, to enable effective intervention.

Ribonucleotide reductase small subunit p53R2 suppresses MEK-ERK activity by binding to ERK kinase 2.

The p53-dependent RR small subunit (p53R2) protein, a newly identified member of the ribonucleotide reductase family, plays a key role in the p53-dependent cellular response to DNA. Several recent studies have suggested that p53R2 also plays an important role in suppressing the invasive potential of human cancer cells. However, the cellular mechanism that regulates invasiveness remains largely unknown. In this study, we show that p53R2 interacts with MEK2 (extracellular signal-regulated kinase (ERK) kinase 2-mitogen-activated protein kinase (MAPK) kinase 2), the molecule immediately upstream of ERK in the Ras-Raf-MAPK signaling cascade. In co-immunoprecipitation and immunofluorescence analyses, we found that p53R2 and MEK2 interact physically in cultured mammalian cells, and that the p53R2 segment comprising amino acids 161-206 is critical for this interaction. Moreover, serum-induced phosphorylation of MEK1/2 and ERK1/2 was greatly augmented in human cancer cells expressing small-interfering RNA against p53R2. On the other hand, phosphorylation of MEK1/2 and ERK1/2 in human cancer cells was markedly attenuated by overexpression of p53R2. Furthermore, MEK2 was required for p53R2 knockdown-induced enhancement of the invasive ability and anchorage-independent growth of human lung cancer H1299 cells. Taken together, these findings show that p53R2 negatively modulates serum-induced MEK-ERK activity and inhibits the MEK-ERK-mediated malignancy potential of human cancer cells.