Stewardship / Resistance Scan for Aug 26, 2019


Study supports multiple-bed room strategy for isolating ESBL patients

A study conducted in Dutch hospitals has found that an isolation strategy of contact precautions in a multiple-bed hospital room was non-inferior to a strategy of contact precautions in a single-bed room for preventing the spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, Dutch researchers reported in The Lancet Infectious Diseases.

In the cluster-randomized, crossover study, medical and surgical wards at 16 Dutch hospitals applied, over two study periods, contact precautions in either a single-bed or multiple-bed hospital room as the preferred strategy for isolating patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample. Under current European Society for Clinical Microbiology and Infectious Diseases guidelines, contact precautions (i.e., use of gloves and gowns for all direct contact with a patient) are recommended for such patients, preferably in a single room, but studies on the added benefit of a single room have been inconsistent. Compared with other multidrug-resistant pathogens, ESBL-producing Enterobacteriaceae have the highest prevalence in European hospitals and have become an increasing burden.

The hospitals were assigned in a 1:1 ratio to either strategy during the first study period, then switched strategies in the second study period. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient’s isolates. The non-inferiority margin was 10%.

Thirteen hospitals completed both study periods and assessed 1,652 index patients and 12,875 wardmates for eligibility from April 2011 through February 2014. Of those, 693 index patients and 9,527 wardmates were enrolled, with 463 index patients and 7,093 wardmates included in the per-protocol population. For the per-protocol population, transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified for 11 of 275 index patients (4%) during the single-bed room strategy period and for 14 of 188 index patients (7%) during the multiple-bed room strategy period (crude risk difference 3.4%; 90% confidence interval [CI], −0.3 to 7.1). For both isolation strategies, the median length of hospital stay was 11 days, and the 30-day mortality was 4%.

“Non-inferiority of the multiple-bed room strategy could change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice,” the authors of the study conclude. 
Aug 23 Lancet Infect Dis study


CDC update shows US Candida auris cases continue to rise

The number of confirmed and probable Candida auris cases in the United States rose to 755 as of June 30, reflecting an increase of 39 cases, according to the most recent case-count update from the Centers for Disease Control and Prevention (CDC).

Of the cases reported to the CDC, 30 are probable and 725 have been lab-confirmed. In its previous update, involving cases through May 31, the CDC reported 716 cases. An additional 1,474 patients have been found to be colonized with the multidrug-resistant yeast, as determined by targeted screening in 10 states with clinical cases.

The number of states affected remains at 12, with New York (359), Illinois (199), and New Jersey (148) reporting the vast majority of C auris cases. Other states reporting cases include Florida (22), Massachusetts (8), California (5), Maryland (5), Texas (4), Oklahoma (2), Connecticut (1), Indiana (1), and Virginia (1).

Since it was identified in 2009 in Japan, C auris has triggered outbreaks in healthcare facilities in 23 countries, and 13 countries have reported single cases. C auris can cause serious invasive infections in immunocompromised patients, and has shown resistance to three major antifungal drug classes. The CDC has estimated that 30% to 60% of patients with infections have died.
Aug 16 CDC update


Resistant Enterobacteriaceae on the rise US hospitals, study finds

An analysis of more than a million Enterobacteriaceae isolates collected from US hospitals has found a rise in ESBL-producing and carbapenem-nonsusceptible Enterobacteriaceae, US researchers reported in BMC Infectious Diseases.

In the study, researchers from Becton, Dickinson and Company and Tetraphase Pharmaceuticals analyzed the antimicrobial susceptibility of non-duplicated isolates from multiple culture sources collected from hospitalized patients at 411 US hospitals from 2013 through 2017. The resistance profiles of interest were ESBL-producing, multidrug-resistant (MDR), and carbapenem-nonsusceptible phenotypes of Enterobacteriaceae, and MDR and carbapenem-nonsusceptible Acinetobacter spp. The outcomes assessed were the rate of bacterial resistance or non-susceptibility per 100 hospital admissions and the proportion of resistant isolates for each year-quarter from Q1 2013 through Q4 2017. 

The analysis found that 12.05% of Enterobacteriaceae isolates were identified as ESBL phenotype, 1.21% were carbapenem-nonsusceptible, and 7.08% were MDR, with urine cultures accounting for the majority of resistant isolates. Of the more 19,000 Acinetobacter isolates tested, 37.48% were identified as carbapenem-nonsusceptible and 47.66% as MDR, and the most common source was skin/wound cultures. Trend analyses showed that the rates of ESBL-producing and carbapenem non-susceptible Enterobacteriaceae per 100 hospital admissions increased significantly between 2013 and 2017, with average slopes of 0.0089 and 0.0004 per quarter, respectively. Rates of MDR Enterobacteriaceae and carbapenem-nonsusceptible and MDR Acinetobacter spp., however, decreased during this time period.

The analysis also found that trends in proportions of resistant isolates generally mirrored trends in rates per 100 hospital admissions, and that MDR Enterobacteriaceae and carbapenem-nonsusceptible and MDR Acinetobacter spp. were more common in winter than summer.

The authors of the study say the observed increase in ESBL-producing and carbapenem-nonsusceptible Enterobacteriaceae supports continuing efforts by the CDC and the World Health Organization to combat these pathogens. They conclude, “Continued infection control efforts, together with diagnostic and antimicrobial stewardship and new antibiotics to expand treatment options, will be required to manage these antibiotic-resistant Gram-negative pathogens.”
Aug 23 BMC Infect Dis study

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