Cluster of Escherichia coli Isolates Producing a Plasmid-Mediated OXA-48 β-Lactamase in a Spanish Hospital in 2012

Three unrelated sequence type 131 (ST131), ST58, and ST83 Escherichia coli isolates with low-level resistance to imipenem and resistance to ertapenem were recovered in a Spanish hospital from July to October 2012. They were positive for bla_OXA-48 carried by an IncL/M conjugative plasmid, which may have been acquired from Klebsiella pneumoniae.     

Safe emergency evacuation of a Tertiary Care Hospital during the “once in a century” floods in Chennai,India

The coastal city of Chennai, India, was inundated by unprecedented heavy rains during the last week of November 2015, in what was billed as a “once in a century” floods. Over 350 people lost their lives in the floods. Global Hospital, a 250-bedded tertiary care hospital in Chennai, was heavily flooded leaving more than 100 patients and their relatives stranded inside with access totally cutoff from the rest of the world. This article describes how these patients, many in the Intensive Care Unit on ventilators, were safely managed within the hospital for over 48 h on very limited power supply and resources and then safely evacuated by fishing boats to three other city hospitals. Careful planning, anticipating hazards, identifying critical areas, effective communication and team work contributed to the successful management of this situation.     

OXA- and GES-type β-lactamases predominate in extensively drug-resistant Acinetobacter baumannii isolates from a Turkish University Hospital

We determined the antibiotic susceptibility and genetic mechanisms of resistance in clinical strains of Acinetobacter baumannii from Istanbul, Turkey. A total of 101 clinical strains were collected between November 2011 and July 2012. Antimicrobial susceptibility was performed using the Vitek 2 Compact system and E-test. Multiplex PCR was used for detecting bla_OXA-51-like, bla_OXA.-_23-like, bla_OXA-40-like and bla_OXA-58-like genes. ISAba1, bla_IMP-like, bla_VIM-like, bla_GES, bla_VEB, bla_PER-2, aac-3-Ia and aac-6'-Ib and NDM-1 genes were detected by PCR and sequencing. By multiplex PCR, all strains were positive for bla_OXA-51, 79 strains carried bla_OXA-23 and one strain carried bla_OXA-40. bla_OXA-51 and bla_OXA-23 were found together in 79 strains. ISAba1 element was detected in 81 strains, and in all cases it was found upstream of bla_OXA-51. GES-type carbapenemases were found in 24 strains (GES-11 in 16 strains and GES-22 in 8 strains) while bla_PER-2, bla_VEB-1, bla_NDM-1, bla_IMP- and bla_VIM-type carbapenemases were not observed. Aminoglycoside modifying enzyme (aac-3-Ia and aac-6'Ib) genes were detected in 13 and 15 strains, respectively. Ninety-seven (96%) A. baumannii strains were defined as MDR and of these, 98% were extensively drug resistant (sensitive only to colistin). Colistin remains the only active compound against all clinical strains. As seen in other regions, OXA-type carbapenemases, with or without an upstream ISAba1, predominate but GES-type carbapenemases also appear to have a significant presence. REP-PCR analysis was performed for molecular typing and all strains were collected into 12 different groups. To our knowledge, this is the first report of GES-11 and OXA-40 in A. baumannii from Turkey.     

Evaluation of Alteplase 1 mg for the Restoration of Occluded Central Venous Access Devices in a Tertiary Care Hospital

Background

Alteplase is a recombinant tissue plasminogen activator that is approved for the treatment of occluded central venous access devices (CVADs) and is commercially available as a 2?mg/2?mL dose. Due to the increasing price of 2?mg/2?mL alteplase vials, our institution switched to using a 1?mg/1?mL dose for certain CVADs. The purpose of this study was to evaluate the use, effectiveness, and cost of a maximum of 2 doses of 1?mg/1?mL alteplase for the restoration of an occluded catheter.

Parenteral nutrition support: Beyond gut feeling? Quality control study of parenteral nutrition practices in a Tertiary Care Hospital

Background:Enteral nutrition (EN) is preferred over parenteral nutrition (PN) in hospitalized patients based on International consensus guidelines. Practice patterns of PN in developing countries have not been documented.Objectives:To assess practice pattern and quality of PN support in a tertiary hospital setting in Chennai, India.Methods:Retrospective record review of patients admitted between February 2010 and February 2012.Results:About 351,008 patients were admitted to the hospital in the study period of whom 29,484 (8.4%) required nutritional support. About 70 patients (0.24%) received PN, of whom 54 (0.18%) received PN for at least three days. Common indications for PN were major gastrointestinal surgery (55.6%), intolerance to EN (25.9%), pancreatitis (5.6%), and gastrointestinal obstruction (3.7%).Conclusions:The proportion of patients receiving PN was very low. Quality issues were identified relating to appropriateness of indication and calories and proteins delivered. This study helps to introspect and improve the quality of nutrition support.     

Prevalence of metallo-��-lactamase producing Pseudomonas aeruginosa and Acinetobacter species in intensive care areas in a tertiary care hospital

A total of 39 non-duplicate isolates of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species isolated from blood and endotracheal secretions were tested for metallo-β-lactamase (MBL) production by modified-EDTA disc synergy and double disc synergy tests. The prevalence of MBLs was 33.33% by both the above tests. All patients with MBL-positive isolates were multidrug resistant and had multiple risk factors like > 8 days hospital stay, catheterization, IV lines, previous antibiotic use, etc. These were risk factors for imipenem resistance also. The overall mortality in MBL-positive patients was 46.15%.     

Large Oligoclonal Outbreak Due to Klebsiella pneumoniae ST14 and ST26 Producing the FOX-7 AmpC β-Lactamase in a Neonatal Intensive Care Unit

A large outbreak caused by expanded-spectrum cephalosporin-resistant Klebsiella pneumoniae (ESCRKP) was observed in a neonatal intensive care unit (NICU) in central Italy. The outbreak involved 127 neonates (99 colonizations and 28 infections, with seven cases of sepsis and two deaths) over a period of more than 2 years (February 2008 to April 2010). Characterization of the 92 nonredundant isolates that were available for further investigation revealed that all of them except one produced the FOX-7 AmpC-type β-lactamase and belonged to either sequence type 14 (ST14) or ST26. All of the FOX-7-positive isolates were resistant to cefotaxime, ceftazidime, and piperacillin-tazobactam, while 76% were susceptible to cefepime, 98% to ertapenem, 99% to meropenem, and 100% to imipenem. The two carbapenem-nonsusceptible isolates had alterations in the genes encoding outer membrane proteins K35 and K36, which resulted in truncated and likely nonfunctional proteins. The outbreak was eventually controlled by the reinforcement of infection control measures based on a multitiered interventional approach. This is the first report of a large NICU outbreak caused by ESCRKP producing an AmpC-type enzyme. This study demonstrates that AmpC-type enzyme-producing strains can cause large outbreaks with significant morbidity and mortality effects (the mortality rate at 14 days was 28.5% for episodes of sepsis), and it underscores the role of laboratory-based surveillance and infection control measures to contain similar episodes.     

Nosocomial Outbreak of a Non-Cefepime-Susceptible Ceftazidime-Susceptible Pseudomonas aeruginosa Strain Overexpressing MexXY-OprM and Producing an Integron-Borne PSE-1 ?-Lactamase

Cefepime (FEP) and ceftazidime (CAZ) are broad-spectrum cephalosporins that display similar MICs for wild-type Pseudomonas aeruginosa strains. Recently, P. aeruginosa isolates showing a discordance in susceptibility to CAZ and FEP have been noted at the Hospital de Bellvitge in Barcelona, Spain, and a clustering was suspected. During the study period (March to December 2007), 51 patients, particularly those in an intensive care units (ICUs) (n = 29 [57%]), infected or colonized with at least one P. aeruginosa non-FEP-susceptible and CAZ-susceptible (Fep^ns Caz^s) phenotype strain were detected. Twenty-three (45%) patients were infected, and the respiratory tract was the most frequent site of infection. Changes in the consumption of antimicrobials in the ICUs were observed over time: a progressive reduction in the levels of consumption of carbapenems (247 defined daily doses [DDD]/1,000 patient days to 66 DDD/1,000 patient days; P = 0.008), after restriction of its use in 2006, and an expected increase in the rate of piperacillin-tazobactam use (42 DDD/1,000 patient days in 2004 to 200 DDD/1,000 patient days in 2007; P < 0.001). Throughout the whole study period, only a single clone of a P. aeruginosa Fep^ns Caz^s phenotype strain was identified by pulsed-field gel electrophoresis analysis to be associated with the hyperexpression of MexXY-OprM and the production of an integron-borne PSE-1 ß-lactamase. In conclusion, we identified an epidemic P. aeruginosa clone of an Fep^ns Caz^s phenotype strain involving 51 patients, in particular, ICU patients. The combination of the overexpression of an efflux pump and PSE-1 ß-lactamase production is associated with the multidrug-resistant phenotype. The dominant use of a single class of antibiotics could have provided the selective pressure required for the emergence and spread of this P. aeruginosa strain.Pseudomonas aeruginosa is an opportunistic pathogen that causes a variety of nosocomial infections. Cefepime (FEP) and ceftazidime (CAZ) are broad-spectrum cephalosporins that display similar MICs for wild-type P. aeruginosa strains. Although the rates of susceptibility of these two antipseudomonal cephalosporins appear to be identical for P. aeruginosa isolates in the United States (20), several European studies have recently reported an unusual discordance in the MICs of FEP and CAZ (4, 6, 7), with P. aeruginosa isolates being less susceptible to the former cephalosporin.The most frequent mechanisms of resistance to extended-spectrum cephalosporins in P. aeruginosa are derepression of the chromosomal AmpC ß-lactamase, the impermeability of the outer membrane, and increased efflux (9). FEP, in contrast to CAZ, is efficiently extruded by various efflux pumps, including the MexCD-OprJ and MexXY-OprM efflux pumps (16, 22). In addition, previous studies have noted the selectively reduced susceptibility to FEP among P. aeruginosa strains producing OXA ß-lactamases (2), as opposed to those that produce class A extended-spectrum ß-lactamases (32), which usually confer resistance to CAZ and FEP.In response to an increase in the incidence of carbapenem-resistant and multidrug-resistant P. aeruginosa isolates in the Hospital de Bellvitge, Barcelona, Spain, since 2004, a microbiology surveillance program was introduced. Recently, however, P. aeruginosa isolates showing variable susceptibilities to carbapenems and a discordance in susceptibility between CAZ and FEP have been noted. A clustering of the P. aeruginosa non-FEP-susceptible and CAZ-susceptible (Fep^ns Caz^s) phenotype was suspected in the hospital''s intensive care unit (ICUs). Here we elucidate the clinical and molecular epidemiology of the isolates with this discordant phenotype and the resistance mechanisms involved.     

Is there a Role of Palliative Care in the Neonatal Intensive Care Unit in India?

Recent advances in medical care have improved the survival of newborn babies born with various problems. Despite this death in the neonatal intensive care unit (NICU) is an inevitable reality. For babies who are not going to "get better," the health care team still has a duty to alleviate the physical suffering of the baby and to support the family. Palliative care is a multidisciplinary approach to relieve the physical, psycho social, and spiritual suffering of patients and their families. Palliative care provision in the Indian NICU settings is almost nonexistent at present. In this paper we attempt to "build a case" for palliative care in the Indian NICU setting.     

Imipenem Resistance in Klebsiella pneumoniae Is Associated to the Combination of Plasmid-Mediated CMY-4 AmpC β-Lactamase and Loss of an Outer Membrane Protein

This study was conducted to identify the molecular mechanisms of imipenem resistance in a Klebsiella pneumoniae (Kp16137) isolate recovered in August 2008 at the University Hospital Sahloul, Sousse, Tunisia. The strain was identified with the API 20E system; antibiotic-containing disks were used for detection of antibiotic susceptibility by a disk diffusion assay. We investigated the presence of β-lactamases by PCR, using specific primers for bla(TEM), bla(SHV), bla(CTX-M), bla(OXA), bla(CMY), bla(ACC), bla(FOX), bla(IMP), bla(KPC), bla(VIM), and by sequencing. Extraction of plasmid DNA from Kp16137 and the transconjugant was performed by the method of Kado. Southern transfer was performed on nylon. The membrane was hybridized with a specific probe for the bla(CMY-2) gene. Outer membrane proteins were isolated and were examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis on 12% polyacrylamide gel. K. pneumoniae Kp16137 was resistant to all available β-lactams, including third generation cephalosporins and carbapenems. The screening of β-lactamases showed the presence of three β-lactamases: TEM-1, SHV-61, and CMY-4. The CMY-4 β-lactamase was located on an 80-kb plasmid. An analysis of the outer membrane proteins of this isolate revealed that it lacked a porin of 42?kDa. The loss of this outer membrane protein band correlated with imipenem resistance in this strain. In K. pneumoniae 16137, synthesis of a plasmid-mediated β-lactamase: AmpC CMY-4, together with alteration in permeability led to resistance to all available β-lactams and carbapenems.     

Molecular epidemiology of Acinetobacter baumannii and Acinetobacter nosocomialis in Germany over a 5-year period (2005–2009)

To investigate the species distribution within the Acinetobacter calcoaceticus–Acinetobacter baumannii complex and the molecular epidemiology of A. baumannii and Acinetobacter nosocomialis, 376 Acinetobacter isolates were collected prospectively from hospitalized patients at 15 medical centres in Germany during three surveillance studies conducted over a 5-year period. Species identification was performed by molecular methods. Imipenem minimum inhibitory concentrations (MIC) were determined by broth microdilution. The prevalence of the most common carbapenemase-encoding genes was investigated by oxacillinase (OXA) -multiplex polymerase chain reaction (PCR). The molecular epidemiology was investigated by repetitive sequence-based PCR (rep-PCR; DiversiLab?). Acinetobacter pittii was the most prevalent Acinetobacter species (n = 193), followed by A. baumannii (n = 140), A. calcoaceticus (n = 10) and A. nosocomialis (n = 8). The majority of A. baumannii was represented by sporadic isolates (n = 70, 50%) that showed unique rep-PCR patterns, 25 isolates (18%) clustered with one or two other isolates, and only 45 isolates (32%) belonged to one of the previously described international clonal lineages. The most prevalent clonal lineage was international clone (IC) 2 (n = 34) and IC 1 (n = 6). According to CLSI, 25 A. baumannii isolates were non-susceptible to imipenem (MIC ≥ 8 mg/L), all of which produced an OXA-58-like or OXA-23-like carbapenemase. The rate of imipenem susceptibility among A. baumannii isolates decreased from 96% in 2005 to 76% in 2009. All other Acinetobacter isolates were susceptible to imipenem. The population structure of carbapenem-susceptible A. baumannii in Germany is highly diverse. Imipenem non-susceptibility was strongly associated with the clonal lineages IC 2 and IC 1. These data underscore the high clonality of carbapenem-resistant A. baumannii isolates.     

Meningitis Caused by Escherichia coli Producing TEM-52 Extended-Spectrum β-Lactamase within an Extensive Outbreak in a Neonatal Ward: Epidemiological Investigation and Characterization of the Strain

Outbreaks caused by Enterobacteriaceae isolates producing extended-spectrum β-lactamases (ESBL) in neonatal wards can be difficult to control. We report here an extensive outbreak in a neonatal ward with a case of meningitis caused by an ESBL-producing Escherichia coli strain. Between 24 March and 29 April 2009, among the 59 neonates present in the ward, 26 neonates with ESBL-producing E. coli rectal colonization were detected (44%). One of the colonized neonates developed meningitis with a favorable outcome after treatment combining imipenem, gentamicin, and ciprofloxacin. Despite strict intensification of hygiene and isolation procedures for more than 1 month, ward closure to new admissions was necessary to control the outbreak. Randomly amplified polymorphic DNA and pulsed-field gel electrophoresis analysis performed on 31 isolates recovered from 26 neonates and two mother''s milk samples showed a clonal strain. ESBL PCR assays indicated that the strain harbored a TEM-52 ESBL encoded by an IncI1 replicon. Phylogenetic analysis by multilocus sequence typing showed that the strain belonged to rare phylogenetic group C, which is closely related to group B1 but appears as group A by the triplex PCR phylogrouping method. The strain harbored the virulence genes fuyA, aer, and iroN and was virulent in a mouse model of septicemia. This work indicates the high potential of colonization, transmission, and virulence of some ESBL-producing E. coli clones.With Streptococcus agalactiae, Escherichia coli is one of the two most common bacterial species frequently responsible of neonatal infections (34). E. coli is the second leading cause of neonatal bacterial meningitis in industrial countries, and recent studies suggest that extraintestinal pathogenic E. coli isolates belong mainly to phylogenetic group B2 (2, 6). An increased rate of E. coli ampicillin resistance after the initiation of intrapartum antimicrobial prophylaxis was previously reported (5, 34). However, most of the E. coli isolates remained susceptible to extended-spectrum cephalosporins (ESC), but currently, extended-spectrum β-lactamases (ESBL) are becoming an increasingly important cause of resistance to ESC in E. coli, frequently involving the CTX-M-type enzymes (29). In 2008, Boyer-Mariotte et al. reported one case of fatal neonatal meningitis caused by a CTX-M-15-producing E. coli strain (7). Emergence of ESBL-producing Enterobacteriaceae is a major problem, since the choice of drugs for antimicrobial treatment is limited; moreover, such strains have been increasingly implicated in nosocomial outbreaks in neonatal intensive care units (11, 23, 33, 35). While the spread of CTX-M-type ESBL in the family Enterobacteriaceae, especially in E. coli, has been described worldwide (11, 13, 15, 17), the spread of TEM-type ESBL has been less frequently reported (8, 9). We report here a case of neonatal meningitis caused by a TEM-52 ESBL-producing E. coli strain within a serious outbreak among neonates with rectal colonization and the characteristics of the strain.