Prevalence of carbapenem resistance and carbapenemase production among Enterobacteriaceae isolated from urine in the UK: results of the UK infection-Carbapenem Resistance Evaluation Surveillance Trial (iCREST-UK).

Objectives: Although carbapenem susceptibility testing has been recommended for all Enterobacteriaceae from clinical specimens, for practical reasons a carbapenem is not included in many primary antibiotic panels for urine specimens. The 'iCREST' study sought carbapenemase-producing Enterobacteriaceae (CPE) in routine urine specimens yielding Gram-negative growth in five diagnostic laboratories in the UK. We sought also to compare locally and centrally determined MICs of meropenem and ceftazidime/avibactam. Methods: Positive growth from up to 2000 urine specimens per laboratory was plated onto chromID® CARBA SMART agar. Suspected CPE colonies were tested locally by Etest for susceptibility to meropenem and ceftazidime/avibactam, and referred to central laboratories for PCR confirmation of CPE status and microbroth MIC determination. Results: Twenty-two suspected CPE were identified from 7504 urine specimens. Ten were confirmed by PCR to have NDM (5), IMP (2), KPC (2) or OXA-48-like (1) carbapenemases. Locally determined ceftazidime/avibactam MICs showed complete categorical agreement with those determined centrally by microbroth methodology. The seven ceftazidime/avibactam-resistant isolates (MICs ≥256 mg/L) had NDM or IMP metallo-carbapenemases. Conclusions: The frequency of confirmed CPE among Gram-negative urinary isolates was low, at 0.13% (10/7504), but CPE were found in urines at all five participating sites and the diversity of carbapenemase genes detected reflected the complex epidemiology of CPE in the UK. These data can inform local policies about the cost-effectiveness and clinical value of testing Gram-negative bacteria from urine specimens routinely against a carbapenem as part of patient management and/or infection prevention and control strategies.

Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India.

BACKGROUND & OBJECTIVES: Hospital-acquired infections (HAIs) are a major challenge to patient safety and have serious public health implications by changing the quality of life of patients and sometimes causing disability or even death. The true burden of HAI remains unknown, particularly in developing countries. The objective of this study was to estimate point prevalence of HAI and study the associated risk factors in a tertiary care hospital in Pune, India. METHODS: A series of four cross-sectional point prevalence surveys were carried out between March and August 2014. Data of each patient admitted were collected using a structured data entry form. Centers for Disease Control and Prevention guidelines were used to identify and diagnose patients with HAI. RESULTS: Overall prevalence of HAI was 3.76 per cent. Surgical Intensive Care Unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have significant association with HAI. Prolonged hospital stay [odds ratio (OR=2.81), mechanical ventilation (OR=18.57), use of urinary catheter (OR=7.89) and exposure to central air-conditioning (OR=8.59) had higher odds of acquiring HAI (P<0.05). INTERPRETATION & CONCLUSIONS: HAI prevalence showed a progressive reduction over successive rounds of survey. Conscious effort needs to be taken by all concerned to reduce the duration of hospital stay. Use of medical devices should be minimized and used judiciously. Healthcare infection control should be a priority of every healthcare provider. Such surveys should be done in different healthcare settings to plan a response to reducing HAI.

Fluoroquinolone resistant rectal colonization predicts risk of infectious complications after transrectal prostate biopsy.

PURPOSE: Infection after transrectal prostate biopsy has become an increasing concern due to fluoroquinolone resistant bacteria. We determined whether colonization identified by rectal culture can identify men at high risk for post-transrectal prostate biopsy infection. MATERIALS AND METHODS: Six institutions provided retrospective data through a standardized, web based data entry form on patients undergoing transrectal prostate biopsy who had rectal culture performed. The primary outcome was any post-transrectal prostate biopsy infection and the secondary outcome was hospital admission 30 days after transrectal prostate biopsy. We used chi-square and logistic regression statistical analysis. RESULTS: A total of 2,673 men underwent rectal culture before transrectal prostate biopsy from January 1, 2007 to September 12, 2013. The prevalence of fluoroquinolone resistance was 20.5% (549 of 2,673). Fluoroquinolone resistant positive rectal cultures were associated with post-biopsy infection (6.6% vs 1.6%, p <0.001) and hospitalization (4.4% vs 0.9%, p <0.001). Fluoroquinolone resistant positive rectal culture increased the risk of infection (OR 3.98, 95% CI 2.37-6.71, p <0.001) and subsequent hospital admission (OR 4.77, 95% CI 2.50-9.10, p <0.001). If men only received fluoroquinolone prophylaxis, the infection and hospitalization proportion increased to 8.2% (28 of 343) and 6.1% (21 of 343), with OR 4.77 (95% CI 2.50-9.10, p <0.001) and 5.67 (95% CI 3.00-10.90, p <0.001), respectively. The most common fluoroquinolone resistant bacteria isolates were Escherichia coli (83.7%). Limitations include the retrospective study design, nonstandardized culture and interpretation of resistance methods. CONCLUSIONS: Colonization of fluoroquinolone resistant organisms in the rectum identifies men at high risk for infection and subsequent hospitalization from prostate biopsy, especially in those with fluoroquinolone prophylaxis only.

Decline and fall of epidemic meticillin-resistant Staphylococcus aureus-16.

Epidemic meticillin-resistant Staphylococcus aureus-16, which was widespread throughout the UK and the rest of the world, has declined markedly in recent years. The reasons for this are not clear.

Adding amikacin to fluoroquinolone-based antimicrobial prophylaxis reduces prostate biopsy infection rates.

OBJECTIVE: • To examine the efficacy of adding amikacin to fluoroquinolone-based antimicrobial prophylaxis in preventing transrectal ultrasonography-guided prostate biopsy (TGB) associated infections. PATIENTS AND METHODS: • Infections after TGB were compared before adding amikacin to antimicrobial prophylaxis (2006) with those that occurred after adding amikacin to the prophylaxis (2007 and 2008). • During both periods antimicrobial prophylaxis consisted of ciprofloxacin, co-amoxiclav and metronidazole except after August 2008 when co-amoxiclav was discontinued. • Amikacin was added to the prophylaxis protocol in the period 2007 and 2008. RESULTS: • Before adding amikacin 11 of 281 (3.9%) patients developed infections after TGB (seven urinary tract infections (UTIs) and seven bacteraemias) whereas after adding amikacin six UTIs and two bacteraemias occurred in 590 (1.4%) patients. • In both periods, most of the strains causing the infections were ciprofloxacin resistant (2006: 13 of 14; 2007 and 2008: seven of eight). • Overall, there is strong statistical evidence that the total infection rate was significantly reduced after the inclusion of amikacin into the prostate biopsy prophylaxis regimen. • In 2007 and 2008 when amikacin was included in prophylaxis, the bacteraemia rate was reduced to just over one-tenth of the rate in 2006 before introducing amikacin (P= 0.002). • Although just failing to reach the conventional significance level of 0.05, the evidence suggests a reduction in UTI by an estimated 60% after adding amikacin. CONCLUSION: • We conclude that adding amikacin to fluoroquinolone-based antimicrobial prophylaxis in areas with high fluoroquinolone resistance confers significant benefit in preventing infections after TGB.

"Somebody else's problem?" Staff perceptions of the sources and control of meticillin-resistant Staphylococcus aureus.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) is endemic within the United Kingdom health care sector. Recent campaigns to reduce health care-associated infection have rested on increasing staff accountability and ownership of the problem and its solutions. However, the existence of reservoirs of colonization in the community now creates ambiguity about sources, which may undermine preventative strategies. METHODS: The theoretical framework of causal attribution was applied to explore staff biases in perceptions and effects on infection control behaviors on both sides of the hospital/care home interface. Forty-four staff from 1 acute care hospital and 53 staff from 6 care homes estimated prevalence, risk, and sources of MRSA. Focus groups (6 care home and 8 hospital) were used to elicit group perceptions. RESULTS: Staff tended to attribute the causes of MRSA to external (not self) human factors including patient risk factors and poor infection control practices of others. Teams tend to attribute their "successes" in infection control to dispositional attributions (good team policy and performance) and attribute "lapses" to situational factors (client group, patient movement, work pressures). CONCLUSION: Variations in information needs, ownership, and infection control practices could be addressed by better interorganizational working and support for staff teams to assess their own responses to the problem.

Prevalence of antimicrobial resistance in intestinal flora of patients undergoing prostatic biopsy: implications for prophylaxis and treatment of infections after biopsy.

OBJECTIVE: To determine the prevalence of antimicrobial resistance in intestinal flora of patients undergoing transrectal ultrasonography (TRUS)-guided prostate biopsies (TGB) and to examine if this information is useful in selecting appropriate antimicrobial agents for prophylaxis and treatment of biopsy-associated infections. PATIENTS AND METHODS: In 2007 and 2008, rectal swabs were cultured from patients before undergoing TGB. Antimicrobial sensitivity of coliforms to amikacin, ciprofloxacin and coamoxiclav was determined. Laboratory records were used to identify patients who had bacteraemia or significant bacteriuria within 30 days of the TGB and the antimicrobial sensitivity pattern of these organisms were compared to those from the rectal swab. RESULTS: Of 592 patients who had TGB, 445 (75.1%) had a rectal swab beforehand; 0.2%,10.6% and 13.3% of the coliforms were resistant to amikacin, ciprofloxacin and coamoxiclav, respectively. After TGB, six patients presented with urinary tract infections (UTI) and two with bacteraemia. All the infections were caused by coliforms except one UTI which was caused by ciprofloxacin-sensitive Pseudomonas aeruginosa. The blood culture isolates were sensitive to amikacin but resistant to ciprofloxacin and coamoxiclav. All the coliforms in the urine were resistant to ciprofloxacin but sensitive to coamoxiclav. Urine isolates were not tested for amikacin sensitivity. There was a strong correlation between the antimicrobial sensitivity of the coliforms from the rectal swabs and those cultured from urine or blood in both patients for amikacin, six of eight for ciprofloxacin and seven of eight for coamoxiclav. CONCLUSIONS: Our study shows that in the coliforms in the bowel flora of our local population there is a relatively high level of resistance to ciprofloxacin and coamoxiclav, and very low level of resistance to amikacin. As there was a strong correlation between the antimicrobial sensitivity of organisms causing infections after TGB and those isolated from the rectal swabs, we conclude that rectal swab cultures before TGB provide useful evidence for selecting appropriate antimicrobials for prophylaxis and treatment of TGB-associated infections.

Prevalence of Neisseria gonorrhoeae infection in young subjects attending community clinics in South London.

OBJECTIVES: To describe the prevalence and epidemiology of gonococcal infection in young subjects attending community clinics in South-East London. METHODS: Subjects <25 years of age participating in the National Chlamydia Screening Programme were tested for gonococcal infection using a nucleic acid amplification test (strand displacement amplification assay). RESULTS: 10 523 tests were performed in 7369 patients (82% female) over a 2-year period in 2004 and 2005. Specimens used for tests were self-taken vulvovaginal swabs (43%), cervical swabs (40%), urine (16%) and urethral swabs (0.9%). Reasons for tests were: screening (67%), diagnosis (27%) and contacts of patients with chlamydia or gonococcus infection (7%). A significantly higher percentage of male subjects were tested as contacts (19% male vs 4% female; p<0.001). Of the 10 117 cases with definite results, 414 were positive (prevalence 4.1%, 95% CI 3.7% to 4.5%). There was a significantly higher prevalence in male subjects (5.7% male v 3.8% female; p<0.001). The average number of tests was 1.4 per patient (range 1-10). Contacts had a significantly higher prevalence (15.5%, p<0.001) than those tested for diagnostic (3.6%) or screening (3.1%) purposes. Multivariate regression analysis confirmed that there was a significantly higher prevalence in black Caribbean (5.8%, OR 2.44), black British/other black (5.6%, OR 2.33) and mixed (5.5%, OR 2.25) than white (2.4%) ethnic groups (p<0.001). Increasing age was significantly associated with lower prevalence (OR = 0.87; 95% CI 0.84 to 0.91; p<0.001). The odds of a positive test decreased by 13% for every year older. CONCLUSION: A community-screening programme has detected a high prevalence of Neisseria gonorrhoeae in South London, especially in teenagers, male subjects and certain ethnic groups.

Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus.

Percutaneous endoscopic gastrostomy (PEG) is widely used to maintain enteral nutrition in patients who are unable to swallow. Peristomal wound infection is the most common complication of this procedure. In a hospital endemic for methicillin-resistant Staphylococcus aureus (MRSA), MRSA can be the most common organism associated with these infections. We have evaluated a strategy consisting of screening, skin decontamination and glycopeptide prophylaxis for preventing PEG-site infections. None of the 34 patients who received the decontamination protocol and glycopeptide prophylaxis (Group A) developed PEG-site infections within one month of surveillance. Two patients were infected with MRSA after that period. One of seven patients who received the decontamination protocol alone (Group B) was infected within the period of surveillance, while another patient was infected after that period. Both were infected with MRSA. None of nine patients who received glycopeptide prophylaxis alone (Group C) were infected. The results suggest that the strategy of screening, decontamination and glycopeptide prophylaxis is effective in the prevention of PEG-site infections with MRSA. Further trials are necessary to confirm these findings.

Neisseria elongata endocarditis: case report and literature review.

We describe a case of infective endocarditis due to Neisseria elongata, and review the literature. N. elongata is a constituent of the normal oral flora and a rare cause of infective endocarditis. Unfamiliarity with the organism and its rod-shaped morphology may lead to a delay in microbiological diagnosis. Although the organism is relatively sensitive to antibiotics, our experience in the management of the described case and a review of previous reports suggest that antibiotic therapy alone may not be sufficient. It is likely that patients with N. elongata endocarditis will require surgery.

Pathology tests: is the time for demand management ripe at last?

With the ever increasing demands for pathology testing within the National Health Service there is a need to manage the demand for these tests. This review discusses strategies for the demand management of requests made by clinicians in the disciplines of biochemistry, haematology, and microbiology. The various approaches that have been used to manage demand will be described, along with specific clinical strategies for demand management.