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Background: The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in hospitalized patients in low- and middle-income countries (LMICs) is poorly described. Although risk factors for ESCrE clinical infection have been studied, little is known of the epidemiology of ESCrE colonization. Identifying risk factors for ESCrE colonization, which can predispose to infection, is therefore critical to inform antibiotic resistance reduction strategies. Methods: This study was conducted in 3 hospitals located in 3 districts in Botswana. In each hospital, we conducted ongoing surveillance in sequential units hospitalwide. All participants had rectal swabs collected which were inoculated onto chromogenic media followed by confirmatory testing using MALDI-TOF MS and VITEK-2. Data were collected via interview and review of the inpatient medical record on demographics, comorbidities, antibiotic use, healthcare exposures, invasive procedures, travel, animal contact, and food consumption. Participants with ESCrE colonization (cases) were compared to noncolonized participants (controls) using bivariable and multivariable analyses to identify risk factors for ESCrE colonization. Results: Enrollment occurred from January 15, 2020, to September 4, 2020, and 469 participants were enrolled. The median age was 42 years (IQR, 31–58) and 320 (68.2%) were female. The median time from hospital admission to date of sampling was 5 days (IQR, 3–12). There were 179 cases and 290 controls (ie, 38.2% of participants were ESCrE colonized). Independent risk factors for ESCrE colonization were a greater number of days on antibiotic, recent healthcare exposure, and tending swine prior to hospitalization. (Table). Conclusions: ESCrE colonization among hospitalized patients was common and was associated with several exposures. Our results suggest prior healthcare exposure may be important in driving ESCrE. The strong link to recent antibiotic use highlights the potential role of antibiotic stewardship interventions for prevention. The association with tending swine suggests that animal husbandry practices may play a role in community exposures, resulting in colonization detected at the time of hospital admission. These findings will help to inform future studies assessing strategies to curb further emergence of hospital ESCrE in LMICs.
We assessed susceptibility patterns to newer antimicrobial agents among clinical carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates from patients in long-term acute-care hospitals (LTACHs) from 2014 to 2015. Meropenem-vaborbactam and imipenem-relebactam nonsusceptibility were observed among 9.9% and 9.1% of isolates, respectively. Nonsusceptibility to ceftazidime-avibactam (1.1%) and plazomicin (0.8%) were uncommon.
Background: Urinary tract infections (UTIs) are common in the inpatient, observation, and emergency department settings. Although many UTI-causing pathogens are susceptible to oral β-lactams, these agents are not tested directly, and susceptibility is extrapolated from other agents. To improve the use of these agents, the University of North Carolina Medical Center (UNCMC) added cephalexin to the susceptibility profile generated with urine culture results in the electronic health record (EHR). We evaluated prescribing trends of cephalexin, other oral β-lactams, fluoroquinolones, and other antibiotics for UTIs in the inpatient setting, before and after the susceptibility reporting change. Methods: An interrupted time-series analysis was conducted. Among 1,491 patients who had positive urine cultures with susceptibilities and received at least 1 antibiotic with a listed UTI indication during their inpatient stay at UNCMC, we measured the weekly prevalence (%) of patients who received each antibiotic group: cephalexin, other oral β-lactams (amoxicillin-clavulanate, cefdinir, cefuroxime), fluoroquinolones (levofloxacin, ciprofloxacin), and ceftriaxone. The study comprised a preintervention period (September 2018–March 2019) and a postintervention period (September 2019–March 2020). The prevalence of each antibiotic or group was plotted over time, and segmented linear regression was used to estimate the impact of the intervention on each antibiotic groups’ time trend. Results: At study baseline in September 2018, the weekly prevalence of antibiotic use was 11% for cephalexin, 26% for other oral β-lactams, 51% for ceftriaxone, and 29% for fluoroquinolones. Fluoroquinolone use decreased steadily throughout the study period, by 11% during the 7-month preintervention period (95% CI, −17% to −5%) and by 8% (95% CI, −13% to −3%) after the intervention (P for trend deflection, .70). In contrast, during the preintervention period, trends were flat for cephalexin, ceftriaxone, and other oral β-lactams (all P for nonzero preintervention slope were >.40). During the postintervention period, use increased for ceftriaxone (6%; 95% CI, 3%–9%). Post-intervention use also increased for cephalexin (5%; 95% CI, −3% to 12%) and other oral β-lactams (4%; 95% CI, −8%, 15%), but these trends were imprecise and not statistically significant at α = .05. Fig. 1 displays trends and raw data for each antibiotic group. Conclusions: The urine culture susceptibility reporting change was associated with small increases in cephalexin and ceftriaxone use, coincident with continued decreasing use of fluoroquinolones, for hospitalized patients with positive urine cultures and a listed UTI indication. Low-resource EHR-based interventions may confer considerable benefit for antimicrobial stewardship efforts in this clinical setting, and larger real-world studies are needed to replicate and contextualize these findings.
Background: Despite clear guidance for appropriate testing of symptomatic patients for Clostridioides difficile testing (McDonald et al), the ideal testing methodology remains unresolved. Laboratories currently use different algorithms that incorporate enzyme immunoassay (EIA) testing for toxin, glutamate dehydrogenase (GDH) antigen, and polymerase chain reaction (PCR) testing in combination or as a single test. At UNC Hospitals, a large academic hospital with nearly 1,000 beds in the ninth most populous state in the United States, patients are currently tested by an EIA test for toxin and GDH antigen first, and discordant toxin/GDH results are referred for PCR testing. Previous studies have demonstrated that detection of toxin by EIA is a better predictor of C. difficile infection (CDI) complications (Polage et al). Methods: We investigated all patients who were tested for C. difficile from July 2018 to June 2019. Within each testing methodology and result, we assessed the percentage of patients with at least 3 loose stools documented within a 24-hour period, percentage with a severe episode based on white blood cell (WBC) counts >15,000 cells/mL, or percentage with a serum creatinine level >1.5 mg/dL. Fisher-type confidence intervals were calculated for each proportion. Results: Patients positive for C. difficile by the EIA method had 66.9% appropriate loose stool documentation (95% CI, 57.4%–75.5%), whereas patients with EIA-indeterminate (toxin negative, GDH positive) and positive by only PCR had 49.7% appropriate loose stool documentation (95% CI, 42.7%–56.8%). C. difficile patients that tested negative had 48.1% appropriate loose stool documentation (95% CI, 46.0–50.2%). In addition, patients positive by the EIA method had nearly double the proportion of severe disease by WBC or creatinine criteria compared to patients who were either positive by PCR or who tested negative (Table 1). Conclusions: Patients positive for C. difficile by the EIA method were statistically more likely to meet criteria for loose stool documentation. There was no statistically significant difference between patients that tested positive only by PCR or who tested negative. The percentage of patients with severe episode criteria based on WBC or creatinine was nearly doubled between those who tested positive by EIA and PCR (20% vs 10%), although this finding was not statistically significant. The percentage with severe disease (WBC or creatinine) was nearly identical among patients who were positive by PCR and who tested negative. These findings demonstrate that documentation of loose stool is a more sensitive indicator of toxin detection than either clinical parameter, reinforcing the importance of stool documentation in evaluating patients for C. difficile testing.
In a cohort of inpatients with hematologic malignancy and positive enzyme immunoassay (EIA) or polymerase chain reaction (PCR) Clostridium difficile tests, we found that clinical characteristics and outcomes were similar between these groups. The method of testing is unlikely to predict infection in this population, and PCR-positive results should be treated with concern.
An improved understanding of carbapenem-resistant Klebsiella pneumoniae (CRKP) in long-term acute care hospitals (LTACHs) is needed. The objective of this study was to assess risk factors for colonization or infection with CRKP in LTACH residents.
A case-control study was performed at a university-affiliated LTACH from 2008 to 2013. Cases were defined as all patients with clinical cultures positive for CRKP and controls were those with clinical cultures positive for carbapenem-susceptible K. pneumoniae (CSKP). A multivariate model was developed to identify risk factors for CRKP infection or colonization.
A total of 222 patients were identified with K. pneumoniae clinical cultures during the study period; 99 (45%) were case patients and 123 (55%) were control patients. Our multivariate analysis identified factors associated with a significant risk for CRKP colonization or infection: solid organ or stem cell transplantation (OR, 5.05; 95% CI, 1.23–20.8; P=.03), mechanical ventilation (OR, 2.56; 95% CI, 1.24–5.28; P=.01), fecal incontinence (OR, 5.78; 95% CI, 1.52–22.0; P=.01), and exposure in the prior 30 days to meropenem (OR, 3.55; 95% CI, 1.04–12.1; P=.04), vancomycin (OR, 2.94; 95% CI, 1.18–7.32; P=.02), and metronidazole (OR, 4.22; 95% CI, 1.28–14.0; P=.02).
Rates of colonization and infection with CRKP were high in the LTACH setting, with nearly half of K. pneumoniae cultures demonstrating carbapenem resistance. Further studies are needed on interventions to limit the emergence of CRKP in LTACHs, including targeted surveillance screening of high-risk patients and effective antibiotic stewardship measures.
Infect. Control Hosp. Epidemiol. 2015;37(1):55–60
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