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In the past several decades, the incidence of Klebsiella pneumoniae harboring resistance mechanisms against multiple antibiotic agents has increased on a global scale. We discuss reasons for ongoing transmission of multidrug-resistant K. pneumoniae in healthcare settings, which has resulted in the successful spread and establishment of this pathogen. It is now one of the most important causes of healthcare-associated infections worldwide.
To determine whether colonization with extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE) predicts the risk for subsequent infection and impacts carbapenem-consumption and outcome in intensive care unit (ICU) patients.
Prospective cohort study.
The 2 ICUs in the University Hospital Basel in Switzerland.
All patients admitted to the 2 ICUs providing mechanical ventilation and an expected ICU stay >48 hours.
Patients were routinely screened for ESBL-PE carriage by rectal swab on admission. Competing risk regression analyses were applied to calculate hazard ratios (HRs) for infection with ESBL-PE and mortality. Length of hospital stay, length of ICU stay, and duration of carbapenem exposure were compared using the Mann-Whitney U test.
Among 302 patients, 24 (8.0%) were colonized with ESBL-PE on ICU admission. Infections with ESBL-PE occurred in 4 patients, of whom 3 (75%) were identified as ESBL-PE colonized on admission. ESBL-PE colonization on admission was associated with subsequent ESBL-PE infection (hazard ratio [HR], 25.52; 95% confidence interval [CI], 2.40–271.41; P = .007) and exposure to carbapenems (HR, 2.42; 95% CI, 1.01–5.79; P = .047), whereas duration of carbapenem exposure did not differ in relation to ESBL-PE colonization (median, 7 days [IQR, 3–8 days] vs median, 6 days [IQR 3–9 days]; P = 0.983). Patients colonized with ESBL-PE were not at increased risk for death overall (HR, 1.00; 95% CI, 0.44–2.30; P = .993) or death attributable to infection (HR, 1.20; 95% CI, 0.28–5.11; P = .808).
Screening strategies for detection of ESBL-PE colonization on ICU admission may allow the identification of patients at highest risk for ESBL-PE infection and the correct allocation of empiric carbapenem treatment.
To evaluate host characteristics, mode of infection acquisition, and infection control procedures in patients with a positive respiratory syncytial virus (RSV) test result after the introduction of the GenXpert Influenza/RSV polymerase chain reaction (PCR) assay.
Retrospective cohort study.
Adults with a positive PCR test result for RSV who were hospitalized in a tertiary academic medical center between January 2015 and December 2016 were included in this study. Our infection control policy applies contact isolation precautions only for immunocompromised patients.
Patients were identified through 2 databases, 1 consisting of patients isolated because of RSV infection and 1 with automatically collected laboratory results. Baseline and clinical characteristics were collected through a retrospective medical chart review. The rate of and clinical factors associated with healthcare-associated RSV infections were evaluated.
In total, 108 episodes in 106 patients hospitalized with a positive Xpert RSV test result were recorded during the study period. Among them, 11 episodes were healthcare-associated infections (HAIs) and 97 were community-acquired infections (CAIs). The mean length of hospital stay (LOS, 40.2 vs 11.2 days), the mean number of room switches (3.5 vs 1.7) and ward switches (1.5 vs 0.4), and the mean numbers of contact patients (9.9 vs 3.8) were significantly longer and higher in the HAI group than in the CAI group (P<.0001). Surveillance of microbiology records and clinical data did not reveal evidence for a cluster or an epidemic during the 2-year observation period.
The introduction of a rapid molecular diagnostic test systematically applied to patients with influenza-like illness may challenge current infection control policies. In our study, patients with HAIs had a prolonged hospital stay and a high number of contact patients, and they switched rooms and wards frequently.
Distinguishing recurrent Clostridium difficile infection (CDI), defined as CDI caused by the same genotype, from reinfection with a different genotype, has important implications for surveillance and clinical trials investigating treatment effectiveness. We validated the proposed 8-week period for distinguishing “same genotype CDI” from “different genotype CDI,” and we aimed to identify clinical variables with distinctiveness to propose an improved definition.
From January 2004 to December 2013, a cohort of all inpatients with CDI at the University Hospital Basel, Switzerland, was established, and respective strains were collected. In patients with a second episode of CDI, both strains were compared using polymerase chain reaction (PCR) ribotyping. The standard definition of recurrence (within 8 weeks after initial diagnosis) was evaluated for its performance to predict CDI caused by the same genotype.
Among 750 patients with CDI, 130 (17.3%) were diagnosed with recurrence or reinfection. Strains from both episodes were available from 106 patients. Identical strains were identified in 36 patients with recurrence (36 of 47) and 27 patients with reinfection (27 of 59). Sensitivity, specificity, and negative and positive predictive values of the standard definition were 56%, 74%, 53%, and 76%, respectively. An extended period of 20 weeks resulted in the best match for both sensitivity and specificity (83% and 58%, respectively), while none of the clinical characteristics revealed independent distinctive power.
Our results challenge the utility of the 8-week cutoff for distinguishing recurrent CDI from reinfection. An extended period of 20 weeks may result in improved overall performance characteristics, but this finding requires external validation.
Clostridium difficile infection (CDI) in hospitalized patients is generally attributed to the current stay, but recent studies reveal high C. difficile colonization rates on admission.
To determine the rate of colonization with toxigenic C. difficile among intensive care unit patients upon admission as well as acquired during hospitalization, and the risk of subsequent CDI.
Prospective cohort study from April 15 through July 8, 2013. Adults admitted to an intensive care unit within 48 hours of admission to the Johns Hopkins Hospital, Baltimore, Maryland, were screened for colonization with toxigenic C. difficile. The primary outcome was risk of developing CDI.
Among 542 patients, 17 (3.1%) were colonized with toxigenic C. difficile on admission and an additional 3 patients were found to be colonized during hospitalization. Both colonization with toxigenic C. difficile on admission and colonization during hospitalization were associated with an increased risk for development of CDI (relative risk, 10.29 [95% CI, 2.24–47.40], P=.003; and 15.66 [4.01–61.08], P<.001, respectively). Using multivariable analysis, colonization on admission and colonization during hospitalization were independent predictors of CDI (relative risk, 8.62 [95% CI, 1.48–50.25], P=.017; and 10.93 [1.49–80.20], P=.019, respectively), while adjusting for potential confounders.
In intensive care unit patients, colonization with toxigenic C. difficile is an independent risk factor for development of subsequent CDI. Further studies are needed to identify populations with higher toxigenic C. difficile colonization rates possibly benefiting from screening or avoidance of agents known to promote CDI.
Infect. Control Hosp. Epidemiol. 2015;36(11):1324–1329
We validated proposed definitions for severe Clostridium difficile infection (CDI) in adults for prediction of complicated CDI in children. Complicated CDI occurred in 9 of 202 cases. Definitions for severe CDI in adults showed poor measures for discrimination of complicated CDI in children, which calls into question the usefulness of such definitions in pediatric cohorts.
Food is an established source of extended-spectrum (β-lactamase (ESBL)-producing Enterobacteriaceae. Hand hygiene and cooking prevent transmission, but hands could be recontaminated by touching used cutting boards. ESBL-producing Escherichia coli were identified on 12% of cutting boards and 50% of gloves after poultry preparation, pointing to an important source for transmission.
Thirty-nine hemodialysis patients with permanent central venous catheters were analyzed for bacterial catheter colonization comparing different catheter-lock strategies. The closed needleless Tego connector with sodium chloride lock solution was significantly more frequently colonized with bacteria than the standard catheter caps with antimicrobially active citrate lock solution (odds ratio, 0.22 [95% confidence interval, 0.07–0.71]; P = .011).
In November 2009, routine sampling of endoscopes performed to monitor the effectiveness of the endoscope-cleaning procedure at our hospital detected Pseudomonas aeruginosa. Herein we report the results of the subsequent investigation.
Design and Methods.
The investigation included environmental cultures for source investigation, molecular analysis by pulsed-field gel electrophoresis (PFGE) to reveal the identity of the strains, and determination of the bactericidal activity of the glutaraldehyde-based disinfectant used for automated endoscope reprocessing. In addition, patient outcome was analyzed by medical chart review, and incidence rates of clinical samples with P. aeruginosa were compared.
The University Hospital of Basel is an 855-bed tertiary care center in Basel, Switzerland. Approximately 1,700 flexible bronchoscopic, 2,500 gastroscopic, 1,400 colonoscopic, 140 endoscopic retrograde cholangiopancreatographic, and 140 endosonographic procedures are performed annually.
P. aeruginosa was detected in samples obtained from endoscopes in November 2009 for the first time since the initiation of surveillance in 2006. It was found in the rinsing water and in the drain of 1 of the 2 automated endoscope reprocessors. PFGE revealed 2 distinct P. aeruginosa strains, one in each reprocessor. The glutaraldehyde-based disinfectant showed no activity against the 2 pseudo-outbreak strains when used in the recommended concentration under standard conditions. After medical chart review, 6 patients with lower respiratory tract and bloodstream infections were identified as having a possible epidemiological link to the pseudo-outbreak strain.
This is the first description of a pseudo-outbreak caused by P. aeruginosa with reduced susceptibility to an aldehyde-based disinfectant routinely used in the automated processing of endoscopes.
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