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1.  Characterization of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and extended-spectrum beta-lactamase-producing Escherichia coli in intensive care units in Canada: Results of the Canadian National Intensive Care Unit (CAN-ICU) study (2005–2006) 
Methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and vancomycin-resistant enterococci (VRE) are important hospital pathogens in Canada and worldwide.
To genotypically and phenotypically characterize the isolates of MRSA, VRE and ESBL-producing E coli collected from patients in Canadian intensive care units (ICUs) in 2005 and 2006.
Between September 1, 2005, and June 30, 2006, 19 medical centres participating in the Canadian National Intensive Care Unit (CAN-ICU) study collected 4133 unique patient isolates associated with infections in ICUs. Isolates of MRSA underwent mecA polymerase chain reaction (PCR) and Panton-Valentine leukocidin analysis; they were typed using pulsed-field gel electrophoresis. All isolates of E coli with ceftriaxone minimum inhibitory concentrations greater than or equal to 1 μg/mL were tested for the presence of an ESBL using the Clinical Laboratory Standards Institute double-disk diffusion method. Subsequently, PCR and sequence analysis were used to identify blaSHV, blaTEM and blaCTX-M. Isolates of VRE were tested for the presence of vanA and vanB genes by PCR.
Of the 4133 ICU isolates collected, MRSA accounted for 4.7% (193 of 4133) of all isolates. MRSA represented 21.9% (193 of 880) of all S aureus collected during the study; 90.7% were health care-associated MRSA strains and 9.3% were community-associated MRSA strains. Resistance rates for the isolates of MRSA were 91.8% to levofloxacin, 89.9% to clarithromycin, 76.1% to clindamycin and 11.7% to trimethoprim-sulfamethoxazole; no isolates were resistant to vancomycin, linezolid, tigecycline or daptomycin. ESBL-producing E coli accounted for 0.4% (18 of 4133) of all isolates and 3.7% (18 of 493) of E coli isolates. All 18 ESBL-producing E coli were PCR-positive for CTX-M, with blaCTX-M-15 occurring in 72% (13 of 18) of isolates. All ESBL-producing E coli displayed a multidrug-resistant phenotype (resistant to third-generation cephalosporins and one or more other classes of antimicrobials), with 77.8% of isolates resistant to ciprofloxacin, 55.6% resistant to trimethoprim-sulfamethoxazole, 27.8% resistant to gentamicin and 26.3% resistant to doxycycline; all isolates were susceptible to ertapenem, meropenem and tigecycline. VRE accounted for 0.4% (17 of 4133) of all isolates and 6.7% (17 of 255) of enterococci isolates; 88.2% of VRE had the vanA genotype. Isolated VRE that were tested were uniformly susceptible to linezolid, tigecycline and daptomycin.
MRSA isolated in Canadian ICUs in 2005 and 2006 was predominately health care-associated (90.7%), ESBL-producing E coli were all CTX-M producers (72% blaCTX-M-15) and VRE primarily harboured a vanA genotype (88.2%). MRSA, ESBL-producing E coli and VRE were frequently multidrug resistant.
PMCID: PMC2605872  PMID: 19412382
CAN-ICU; ESBL E coli; Intensive care; MRSA; Resistance; VRE
2.  Emergence of Colistin Resistance in Enterobacteriaceae after the Introduction of Selective Digestive Tract Decontamination in an Intensive Care Unit 
Selective decontamination of the digestive tract (SDD) selectively eradicates aerobic Gram-negative bacteria (AGNB) by the enteral administration of oral nonabsorbable antimicrobial agents, i.e., colistin and tobramycin. We retrospectively investigated the impact of SDD, applied for 5 years as part of an infection control program for the control of an outbreak with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in an intensive care unit (ICU), on resistance among AGNB. Colistin MICs were determined on stored ESBL-producing K. pneumoniae isolates using the Etest. The occurrence of both tobramycin resistance among pathogens intrinsically resistant to colistin (CIR) and bacteremia caused by ESBL-producing K. pneumoniae and CIR were investigated. Of the 134 retested ESBL-producing K. pneumoniae isolates, 28 were isolated before SDD was started, and all had MICs of <1.5 mg/liter. For the remaining 106 isolated after starting SDD, MICs ranged between 0.5 and 24 mg/liter. Tobramycin-resistant CIR isolates were found sporadically before the introduction of SDD, but their prevalence increased immediately afterward. Segmented regression analysis showed a highly significant relationship between SDD and resistance to tobramycin. Five patients were identified with bacteremia caused by ESBL-producing K. pneumoniae before SDD and 9 patients thereafter. No bacteremia caused by CIR was found before SDD, but its occurrence increased to 26 after the introduction of SDD. In conclusion, colistin resistance among ESBL-producing K. pneumoniae isolates emerged rapidly after SDD. In addition, both the occurrence and the proportion of tobramycin resistance among CIR increased under the use of SDD. SDD should not be applied in outbreak settings when resistant bacteria are prevalent.
PMCID: PMC3697390  PMID: 23629703
3.  Extended Spectrum β-Lactamases among Gram-negative bacteria of nosocomial origin from an Intensive Care Unit of a tertiary health facility in Tanzania 
Resistance to third generation cephalosporins due to acquisition and expression of extended spectrum β-lactamase (ESBL) enzymes among Gram-negative bacteria is on the increase. Presence of ESBL producing organisms has been reported to significantly affect the course and outcome of an infection. Therefore infections due to ESBL isolates continue to pose a challenge to infection management worldwide. The aim of this study was to determine the existence and to describe phenotypic and genotypic characteristics of ESBLs in an Intensive Care Unit (ICU) setting in Tanzania.
Between October 2002 and April 2003, clinical information and samples were collected from patients suspected to have nosocomial infections in an Intensive Care Unit of a tertiary hospital in Tanzania. The isolates were identified, tested for antimicrobial susceptibility and analysed for presence of ESBL genes.
Thirty-nine Gram-negative bacteria were isolated from clinical samples of 39 patients. These isolates included 13 Escherichia coli, 12 Enterobacter spp, 5 Pseudomonas spp, 4 Proteus spp, 2 Klebsiella. pneumoniae, 2 Citrobacter freundii and 1 Chryseomonas luteola. Eleven (28.2%) of these isolates were ESBL producing. The ESBL genes characterised were SHV-12, SHV-28 and CTX-M-15. The ESBL producing isolates were more resistant to gentamicin and ciprofloxacin than non-ESBL producing isolates.
This study shows the presence of ESBL genes among Gram-negative bacteria in the ICU setting in Tanzania. There is a need to institute strict hospital infection control policy and a regular surveillance of resistance to antimicrobial agents.
PMCID: PMC1274314  PMID: 16225701
4.  Sequential introduction of single room isolation and hand hygiene campaign in the control of methicillin-resistant Staphylococcus aureus in intensive care unit 
BMC Infectious Diseases  2010;10:263.
After renovation of the adult intensive care unit (ICU) with installation of ten single rooms, an enhanced infection control program was conducted to control the spread of methicillin-resistant Staphylococcus aureus (MRSA) in our hospital.
Since the ICU renovation, all patients colonized or infected with MRSA were nursed in single rooms with contact precautions. The incidence of MRSA infection in the ICU was monitored during 3 different phases: the baseline period (phase 1); after ICU renovation (phase 2) and after implementation of a hand hygiene campaign with alcohol-based hand rub (phase 3). Patients infected with extended spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species were chosen as controls because they were managed in open cubicles with standard precautions.
Without a major change in bed occupancy rate, nursing workforce, or the protocol of environmental cleansing throughout the study period, a stepwise reduction in ICU onset nonbacteraemic MRSA infection was observed: from 3.54 (phase 1) to 2.26 (phase 2, p = 0.042) and 1.02 (phase 3, p = 0.006) per 1000-patient-days. ICU onset bacteraemic MRSA infection was significantly reduced from 1.94 (phase 1) to 0.9 (phase 2, p = 0.005) and 0.28 (phase 3, p = 0.021) per 1000-patient-days. Infection due to ESBL-producing organisms did not show a corresponding reduction. The usage density of broad-spectrum antibiotics and fluoroquinolones increased from phase 1 to 3. However a significant trend improvement of ICU onset MRSA infection by segmented regression analysis can only be demonstrated when comparison was made before and after the severe acute respiratory syndrome (SARS) epidemic. This suggests that the deaths of fellow healthcare workers from an occupational acquired infection had an overwhelming effect on their compliance with infection control measures.
Provision of single room isolation facilities and promotion of hand hygiene practice are important. However compliance with infection control measures relies largely on a personal commitment, which may increase when personal safety is threatened.
PMCID: PMC2944349  PMID: 20822509
5.  Prevalence of Newer β-Lactamases in Gram-Negative Clinical Isolates Collected in the United States from 2001 to 2002 
Journal of Clinical Microbiology  2006;44(9):3318-3324.
Newer β-lactamases such as extended-spectrum β-lactamases (ESBLs), transferable AmpC β-lactamases, and carbapenemases are associated with laboratory testing problems of false susceptibility that can lead to inappropriate therapy for infected patients. Because there appears to be a lack of awareness of these enzymes, a study was conducted during 2001 to 2002 in which 6,421 consecutive, nonduplicate clinical isolates of aerobically growing gram-negative bacilli from patients at 42 intensive care unit (ICU) and 21 non-ICU sites across the United States were tested on-site for antibiotic susceptibility. From these isolates, 746 screen-positive isolates (11.6%) were referred to a research facility and investigated to determine the prevalence of ESBLs in all gram-negative isolates, transferable AmpC β-lactamases in Klebsiella pneumoniae, and carbapenemases in Enterobacteriaceae. The investigations involved phenotypic tests, isoelectric focusing, β-lactamase inhibitor studies, spectrophotometric assays, induction assays, and molecular analyses. ESBLs were detected only in Enterobacteriaceae (4.9% of all Enterobacteriaceae) and were found in species other than those currently recommended for ESBL testing by the CLSI (formerly NCCLS). These isolates occurred at 74% of the ICU sites and 43% of the non-ICU sites. Transferable AmpC β-lactamases were detected in 3.3% of K. pneumoniae isolates and at 16 of the 63 sites (25%) with no difference between ICU and non-ICU sites. Three sites submitted isolates that produced class A carbapenemases. No class B or D carbapenemases were detected. In conclusion, organisms producing ESBLs and transferable AmpC β-lactamases were widespread. Clinical laboratories must be able to detect important β-lactamases to ensure optimal patient care and infection control.
PMCID: PMC1594717  PMID: 16954267
6.  Carbapenem Restriction and its Effect on Bacterial Resistance in an Intensive Care unit of a Teaching Hospital  
Development of antibiotic resistance in Intensive Care Units (ICUs) is a worldwide problem. The purpose of this study was to evaluate the effect of an antibiotic stewardship program (ASP) by carbapenems restriction on gram-negative antimicrobial resistance in ICU. The study was designed in a 21 bedded general ICU of a teaching hospital with two wings (one and two) in Tehran, Iran. Carbapenem prescription in ICU1 was restricted to only the culture proven multi-drug-resistant bacteria with the absence of sensitivity to other antimicrobial agents. Carbapenem had to be prescribed by a trained ICU physician with close consultation with infectious disease specialist and the clinical pharmacist posted in ICU. Post-prescription reviews and de-escalations were carried out by the same team on regular basis. Restriction policy was commenced in January 2011 in ICU1. All documented infections and resistance patterns of isolated pathogens were recorded in both ICUs during two periods of 6 months before and 9 months after restriction policy implementation. During this study bacterial growth was detected in 51.5% of 1601 samples. Carbapenem administration was decreased from 6.86 to 2.75 DDD/100 patients day (60% decreases) pre-restriction and post-restriction respectively. Significant increase in sensitivity of pseudomonas to imipenem was observed in ICU1 comparing with pre-restriction period six months post restriction (p = 0.000). Sensitivity of Klebsiella and Acinetobacter to imipenem did not change significantly during the study period. Conclusion: Our study demonstrated that restriction of carbapenems can increase sensitivity of P. aeroginosa to imipenem.
PMCID: PMC3813286  PMID: 24250656
7.  Therapeutic challenges of ESBLS and AmpC beta-lactamase producers in a tertiary care center 
Resistance to broad-spectrum beta lactams mediated by extended spectrum beta lactamases (ESBLs) and AmpC beta lactamases (AmpC βLs) enzymes is an increasing problem worldwide. Determination of their prevalence is essential to formulate an effective antibiotic policy and hospital infection control measures. Present study was undertaken to determine the prevalence of ESBL and AmpC βL producers in ICU of a tertiary care center.
A total of 262 clinical isolates comprising of Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis that were recovered from various clinical specimens over a one year period, were studied. Antibiogram profile was determined to conventionally used antibiotics, along with recommended tests for detection of ESBL and AmpC βL production.
40.07% (105/262) were found to be ESBL producers, 14.8% (39/262) were AmpC bL producers. The coexistence of ESBL and AmpC βL producers was detected in 9.9% (26/262) of the isolates.
Screening of multidrug resistant bacteria especially belonging to the Enterobacteriaceae poses considerable therapeutic challenges in critical care patients because of the production of ESBL and AmpC βL. Strategies to keep a check on the emergence of such drug resistant microbes by hospital environmental surveillance and laboratory monitoring should form an important aspect of Hospital Infection control policy guidelines.
PMCID: PMC3862620  PMID: 24532926
Extended spectrum beta lactamase; AmpC beta lactamase; Escherichia coli; Klebsiella pneumoniae
8.  Antibiotic resistance patterns and extended-spectrum β-lactamase production among Acinetobacter spp. isolated from an intensive care Unit of a hospital in Kerman, Iran 
The global increase in multidrug resistance of Acinetobacter spp. has created widespread problems in the treatment of patients in intensive care units (ICUs) of hospitals. To assess the sensitivity of Acinetobacter isolates to antibiotics routinely used in ICUs, we investigated antibiotic resistance patterns and extended-spectrum β-lactamase (ESBL) production among Acinetobacter spp. isolated from the ICU of a university hospital in Kerman, Iran.
Fifteen isolates of Acinetobacter spp. were recovered from one hundred clinical specimens collected from the ICU of Afzalipoor Hospital in Kerman, Iran, from October 2010 to June 2011. Preliminary antibiotic sensitivity testing was carried out using the disk-diffusion breakpoint assay, and MICs of different antibiotics were determined using the E-test. ESBL production was detected by a double-disk synergy test and confirmed by a phenotypic confirmatory test. Substrate hydrolysis in the presence and absence of the following inhibitors was carried out using the rapid fixed-time method: para-chloromercuribenzoate (p-CMB), clavulanic acid, sulbactam, and NaCl.
Overall, 73.3% of the isolates were resistant to imipenem (MIC range 240-128 µg/mL) and 66% to ciprofloxacin (MIC range 240-64 ± 0.08 µg/mL). All of the isolates were fully resistant (MIC 240 µg/mL) to piperacillin, while 93.3%, 53.3%, and 93.3% were resistant to piperacillin + tazobactam (MIC 240 µg/mL), amikacin (MIC range 128-16 µg/mL), and cefepime (MIC range 240-60 µg/mL), respectively. The isolates were also resistant to chloramphenicol and tetracycline: MICs of these two agents were ≥ 240 µg/mL. The test for ESBL production was positive for only three isolates (nos. 1, 10, and 15). The rate of substrate hydrolysis was highest in the presence of p-CMB (80.2 ± 0.02) and lowest in the presence of NaCl (2.1 ± 0.01) (P ≤ 0.05).
Many isolates of Acinetobacter spp. are resistant to almost all antibiotics routinely used in the ICU of our hospital, including imipenem, ciprofloxacin, and piperacillin + tazobactam. Three isolates were ESBL producers. The other isolates exhibited high resistance to β-lactams, but they did not produce any ESBL enzymes.
PMCID: PMC3415115  PMID: 22958725
Acinetobacter spp; antibiotic resistance; MIC; extended-spectrum β-lactamase
9.  Risk of Acquiring Extended-Spectrum β-Lactamase–Producing Klebsiella Species and Escherichia coli from Prior Room Occupants in the Intensive Care Unit 
To quantify the association between admission to an intensive care unit (ICU) room most recently occupied by a patient positive for extended-spectrum β-lactamase (EBSL)–producing gram-negative bacteria and acquisition of infection or colonization with that pathogen.
Retrospective cohort study.
The study included patients admitted to medical and surgical ICUs of an academic medical center between September 1, 2001, and June 30, 2009.
Perianal surveillance cultures were obtained at admission to the ICU, weekly, and at discharge from the ICU. Patients were included if they had culture results that were negative for ESBL-producing gram-negative bacteria at ICU admission and had an ICU length of stay longer than 48 hours. Pulsed-field gel electrophoresis (PFGE) was performed on ESBL-positive isolates from patients who acquired the same bacterial species (eg, Klebsiella species or Escherichia coli) as the previous room occupant.
Among 9,371 eligible admissions (7,651 unique patients), 267 (3%) involved patients who acquired an ESBL-producing pathogen in the ICU; of these patients, 32 (12%) were hospitalized in a room in which the prior occupant had been positive for ESBL. Logistic regression results suggested that the prior occupant's ESBL status was not significantly associated with acquisition of an ESBL-producing pathogen (adjusted odds ratio, 1.39 [95% confidence interval, 0.94–2.08]) after adjusting for colonization pressure and antibiotic exposure in the ICU. PFGE results suggested that 6 (18%) of 32 patients acquired a bacterial strain that was the same as or closely related to the strain obtained from the prior occupant.
These data suggest that environmental contamination may not play a substantial role in the transmission of ESBL-producing pathogens among ICU patients. Intensifying environmental decontamination may be less effective than other interventions in preventing transmission of ESBL-producing pathogens.
PMCID: PMC3660030  PMID: 23571360
10.  Colistin: recent data on pharmacodynamics properties and clinical efficacy in critically ill patients 
Recent clinical studies performed in a large number of patients showed that colistin "forgotten" for several decades revived for the management of infections due to multidrug-resistant (MDR) Gram-negative bacteria (GNB) and had acceptable effectiveness and considerably less toxicity than that reported in older publications. Colistin is a rapidly bactericidal antimicrobial agent that possesses a significant postantibiotic effect against MDR Gram-negative pathogens, such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae. The optimal colistin dosing regimen against MDR GNB is still unknown in the intensive care unit (ICU) setting. A better understanding of the pharmacokinetic-pharmacodynamic relationship of colistin is urgently needed to determine the optimal dosing regimen. Although pharmacokinetic and pharmacodynamic data in ICU patients are scarce, recent evidence shows that the pharmacokinetics/pharmacodynamics of colistimethate sodium and colistin in critically ill patients differ from those previously found in other groups, such as cystic fibrosis patients. The AUC:MIC ratio has been found to be the parameter best associated with colistin efficacy. To maximize the AUC:MIC ratio, higher doses of colistimethate sodium and alterations in the dosing intervals may be warranted in the ICU setting. In addition, the development of colistin resistance has been linked to inadequate colistin dosing. This enforces the importance of colistin dose optimization in critically ill patients. Although higher colistin doses seem to be beneficial, the lack of colistin pharmacokinetic-pharmacodynamic data results in difficulty for the optimization of daily colistin dose. In conclusion, although colistin seems to be a very reliable alternative for the management of life-threatening nosocomial infections due to MDR GNB, it should be emphasized that there is a lack of guidelines regarding the ideal management of these infections and the appropriate colistin doses in critically ill patients with and without multiple organ failure.
PMCID: PMC3224467  PMID: 21906382
11.  Emergence of KPC-producing Klebsiella pneumoniae in Italy 
BMC Research Notes  2010;3:40.
The emergence of KPC-producing K. pneumoniae has now become a global concern. KPC beta-lactamases are plasmid-borne and, like extended spectrum beta lactamases (ESBLs), can accumulate and transfer resistance determinants to other classes of antibiotics. Therefore, infection control guidelines on early identification and control of the spread of organisms carrying these resistant determinants are needed.
Klebsiella pneumoniae carbapenemase (KPC) was detected in two isolates of carbapenem-resistant K. pneumoniae obtained from patients at an Italian teaching hospital. The first strain was isolated from a culture drawn from a central venous device (CVC) in a patient with Crohn's disease who was admitted to a gastroenterology ward. The second was isolated from a urine sample collected from an indwelling urinary catheter in an intensive care unit (ICU) patient with a subdural haematoma. The patients had not travelled abroad. Both isolates were resistant to all β-lactams and were susceptible to imipenem and meropenem but resistant to ertapenem. Isolates also showed resistance to other classes of non-β-lactam antibiotics, such as quinolones, aminoglycosides (with the exception for amikacin), trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin. They were determined to contain the plasmid encoding the carbapenemase gene bla-KPC and were also positive in the Hodge test.
This is the second report of KPC-producing isolates in Italy, but the first concerning KPC type 2 gene, and it may have important implications for controlling the transmission of microorganisms resistant to antibiotics.
PMCID: PMC2844393  PMID: 20178590
12.  Wide variation in adoption of screening and infection control interventions for multidrug-resistant organisms: A national study 
We performed a survey of National Healthcare Safety Network hospitals in 2008 to describe adoption of screening and infection control policies aimed at multidrug-resistant organisms (MDRO) in intensive care units (ICUs) and identify predictors of their presence, monitoring, and implementation.
Four hundred forty-one infection control directors were surveyed using a modified Dillman technique. To explore differences in screening and infection control policies by setting characteristics, bivariate and multivariable logistic regression models were constructed.
In total, 250 hospitals participated (57% response rate). Study ICUs (n = 413) routinely screened for methicillin-resistant Staphylococcus aureus (59%); vancomycin-resistant Enterococcus (22%); multidrug-resistant, gram-negative rods (12%); and Clostridium difficile (11%). Directors reported ICU policies to screen all admissions for any MDRO (40%), screen periodically (27%), utilize presumptive isolation/contact precautions pending a screen (31%), and cohort colonized patients (42%). Several independent predictors of the presence and implementation of different interventions including mandatory reporting and teaching status were identified.
This study found wide variation in adoption of MDRO screening and infection control interventions, which may reflect differences in published recommendations or their interpretation. Further research is needed to provide additional insight on effective strategies and how best to promote compliance.
PMCID: PMC3652550  PMID: 23021413
Infection prevention and control programs; Methicillin-resistant Staphylococcus aureus; Vancomycin-resistant Enterococcus; Clostridium difficile
13.  Value of American Thoracic Society Guidelines in Predicting Infection or Colonization with Multidrug-Resistant Organisms in Critically Ill Patients 
PLoS ONE  2014;9(3):e89687.
The incidence rate of infection by multidrug-resistant organisms (MDROs) can affect the accuracy of etiological diagnosis when using American Thoracic Society (ATS) guidelines. We determined the accuracy of the ATS guidelines in predicting infection or colonization by MDROs over 18 months at a single ICU in eastern China.
This prospective observational study examined consecutive patients who were admitted to an intensive care unit (ICU) in Nanjing, China. MDROs were defined as bacteria that were resistant to at least three antimicrobial classes, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Pseudomonas aeruginosa, Acinetobacter baumannii. Screening for MDROs was performed at ICU admission and discharge. Risk factors for infection or colonization with MDROs were recorded, and the accuracy of the ATS guidelines in predicting infection or colonization with MDROs was documented.
There were 610 patients, 225 (37%) of whom were colonized or infected with MDROs at ICU admission, and this increased to 311 (51%) at discharge. At admission, the sensitivity (70.0%), specificity (31.6%), positive predictive value (38.2%), and negative predictive value (63.5%), all based on ATS guidelines for infection or colonization with MDROs were low. The negative predictive value was greater in patients from departments with MDRO infection rates of 31–40% than in patients from departments with MDRO infection rates of 30% or less and from departments with MDRO infection rates more than 40%.
ATS criteria were not reliable in predicting infection or colonization with MDROs in our ICU. The negative predictive value was greater in patients from departments with intermediate rates of MDRO infection than in patients from departments with low or high rates of MDRO infection.
Trial Registration NCT01667991
PMCID: PMC3960103  PMID: 24647408
14.  Outbreak of multidrug-resistant Klebsiella pneumoniae carrying qnrB1 and blaCTX-M15 in a French intensive care unit 
The prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae is increasing globally and is a major clinical concern. Between June 2008 and September 2009, 4% of patients in an intensive care unit (ICU) were found to be colonized or infected by strains of Klebsiella pneumoniae multiresistant to ceftazidime, ciprofloxacin, and tobramycin; an investigation was initiated and isolates were characterized by molecular typing and resistance patterns.
Antibiotic susceptibilities were determined by Vitek2®, Etest®, and agar dilution. Gene encoding beta-lactamases and plasmid-mediated quinolone resistance PMQR determinants (qnr, aac(6′)-Ib) were characterized by PCR, sequencing, and transfer assays. DiversiLab® fingerprints were used to study the relatedness of isolates.
Fourteen isolates co-expressing blaCTX-M15, qnrB1, and aac(6′)-Ib-cr were identified. Genotypic analysis of these isolates identified 12 clonally related strains recovered from 10 patients. The increased prevalence of blaCTX-M15-qnrB1-aac(6′)-Ib-cr-producing K. pneumoniae coincided with the presence in the ICU of a patient originally from Nigeria. This patient was infected by a strain not clonally related to the others but harbouring qnrB1 and aac(6′)-Ib-cr genes, a finding not hitherto observed in France. We suspected transmission of resistance plasmids followed by rapid dissemination of the multiresistant K. pneumoniae clone by cross-transmission.
This study highlights the importance of microbiological screening for multidrug-resistant strains in ICUs, particularly among patients from regions in which multidrug-resistant bacteria are known to exist.
PMCID: PMC3707830  PMID: 23815782
Outbreak; Klebsiella pneumoniae; Extended-spectrum beta-lactamase; Intensive care unit; Screening; Quinolone resistance
15.  ESBL, MBL and Ampc β Lactamases Producing Superbugs – Havoc in the Intensive Care Units of Punjab India 
Background: An alarming rise in the rates of the antibiotic resistance has now become a serious and an increasingly common public health concern, with severe implications, especially in the intensive care units. A variety of β-lactamases which include ESBLs, AmpC β-lactamases and metallo-βlactamases, have emerged as the most worrisome mechanism of resistance among the gram negative bacteria, which pose a therapeutic challenge to the health care settings.
Materials and Methods: The present study was aimed at knowing the prevalence of various β-lactamases in the gram negative isolates which were obtained from ICU patients. A total 273 gram negative isolates from 913 clinical samples which were received over a period of one year were processed for their identification and their antimicrobial susceptibility pattern was determined. They were then screened for the β-lactamase production.
Results: Among the 273 isolates, the β-lactamase production was observed in 193 strains. 96 (35.16%) strains were ESBL producers, followed by 30 (10.98%) metallo β- lactamase (MBL) producers and 15(5.4%) AmpC producers. The major ESBL and AmpC producer was Escherichia coli, while Klebsiella pneumonia was the predominant MBL producer. The co production of the ESBL/MBL/ AmpC β- lactamases was observed in 52 (19.04%) strains and it was more common in Escherichia coli. A multidrug resistance to the fluoroquinolones and the aminoglycosides was also observed in the β- lactamase producing organisms.
Conclusion: The high prevalence of the β- lactamases in the ICU isolates emphasizes the need for a continuous surveillance in the ICUs to detect the resistant strains, strict guidelines for the antibiotic therapy and the implementation of infection control measures to reduce the increasing burden of antibiotic resistance.
PMCID: PMC3576754  PMID: 23450498
Extended spectrum β-lactamases (ESBLs); AmpC β-lactamases; Metallo-β-lactamases (MBLs); Antibiotic resistance; Intensive care units (ICUs)
16.  Infections Caused by Multi-Drug Resistant Organisms Are Not Associated with Overall, All-Cause Mortality in the Surgical Intensive Care Unit: The 20,000 Foot View 
Resistant pathogens are increasingly common in the Intensive Care Unit (ICU), with controversy regarding their relationship to outcomes. We hypothesized that an increasing number of infections with resistant pathogens in our surgical ICU would not be associated with increased overall mortality.
Study Design
All ICU-acquired infections were prospectively identified between January 1st, 2000 and December 31st, 2009 in a single surgical ICU. Crude in-hospital, all-cause mortality data was obtained using a prospectively collected ICU database. Trends in rates were compared using linear regression.
A total of 799 resistant pathogens were identified (257 gram-positive, 542 gram-negative) from a total of 3024 isolated pathogens associated with 2439 ICU-acquired infections. The most frequently identified resistant gram-positive and -negative pathogens (defined as resistant to at least one major class of antimicrobials) were methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, respectively. Pathogens were most commonly isolated from the lung, blood, and urine. Crude mortality rate declined steadily from 2000–2009 (9.4% to 5.4%; equation for trend y= −0.11x +8.26). Linear regression analysis of quarterly rates revealed a significant divergence in trends between increasing total resistant infections (equation for trend y=0.34x + 13.02) and percentage resistant infections (equation for trend y=0.36x + 18.66) when compared to a decreasing mortality (p = 0.0003, p = <0.0001, respectively).
Despite a steady rise in the proportion of resistant bacterial infections in the ICU, crude mortality rates have decreased over time. The rates of resistant infections do not appear to be a significant factor in overall mortality in our surgical ICU patients.
PMCID: PMC3334453  PMID: 22421258
17.  Phenotypic and Genotypic Methods for Detection of Extended Spectrum β Lactamase Producing Escherichia coli and Klebsiella pneumoniae Isolated from Ventilator Associated Pneumonia 
Background: Ventilator Associated Pneumonia (VAP) is one of the common nosocomial infections associated with high morbidity due to multidrug resistant pathogens. Rapid spread of resistance to broad spectrum beta-lactams in pathogenic strains causes antibiotics ineffectiveness and increased severity of illness. The CTX-M is the most dominant Extended Spectrum β Lactamase (ESBL) among Enterobacteriaceae in many regions of the world. The aim of the study was to identify the occurrence of ESBL and detect the genes responsible for ESBL production by conventional Polymerase Chain Reaction (PCR) method.
Methods: This prospective study included patients, clinically diagnosed as VAP. Endotracheal aspirates (EA) were collected and cultured by quantitative method. The bacterial isolates were identified as per standard methods. Isolates resistant to 3rd generation cephalosporins were screened for ESBL production by disk approximation method and combination disc diffusion method. Isolates confirmed as ESBL producers were subjected to genotyping by conventional PCR.
Statistical Analysis: Statistical analysis was done by using MS Excel sheet. Descriptive statistics like percentage was done in the study.
Results: Among the isolates from 428 patients who developed VAP, 144 isolates belonged to the Enterobacteriaceae family (Klebsiella pneumoniae 87 and Escherichia coli 57). A total of 66 isolates (28 Klebsiella pneumoniae and 38 Escherichia coli) were confirmed as ESBL producer by disc approximation method and 63 isolates by double disc combination method. In the present study by conventional PCR bla CTX-M was the common gene in 48.5% strains followed by 22.22% bla SHV and 14.81% bla TEM.
Conclusion: The genotypic methods using specific PCR amplification of resistance genes seems to have 100% specificity and sensitivity in detection of ESBL when compared to phenotypic methods which lacks the constant sensitivity.
PMCID: PMC3809652  PMID: 24179913
blaTEM gene; blaSHV gene; blaCTX-M gene; Extended Spectrum Beta Lactamase; Polymerase Chain Reaction; Ventilator Associated Pneumonia
18.  Epidemiologically relevant antimicrobial resistance phenotypes in pathogens isolated from critically ill patients in a Brazilian Universitary Hospital 
Brazilian Journal of Microbiology  2008;39(4):623-630.
Antimicrobial resistance is a threat to public health worldwide and is associated with higher mortality and morbidity. Despite the extensive knowledge about this problem, drug resistance has continued to emerge, especially in intensive care units (ICUs). The objective of this study was to evaluate the frequencies of epidemiologically relevant resistance phenotypes in pathogens isolated from ventilator-associated pneumonia (VAP), bloodstream infections (BSI) and urinary tract infections (UTI) in patients admitted in the adult intensive care unit (AICU) of the Clinical Hospital of Federal University of Uberlândia, during an one year period. Additionally, at the period of the study, the antibiotic consumption in AICU was verified. Coagulase-negative staphylococci and S. aureus were the main agents of BSI (43.9%), with 60.0% of oxacilin-resistance for both microorganisms, Klebsiella-Enterobacter group predominated in UTI (23.4%), with resistance to third generation cephalosporins in 58.0% of the isolates; and, Pseudomonas aeruginosa in VAP (42.0%), with 72.0% of resistance to imipenem. Cephalosporins (49.6%), vancomycin (37.4%) and carbapenems (26.6%) were the most prescribed antibiotics in the unit. The comparison of the results with a publication of the NNIS program evidenced a worse situation in the studied hospital, mainly between Gram-negative, that had surpassed the percentile 90% elaborated by that system. Based on these results a reconsideration on the empirical use of antibiotics and on prevention and control of nosocomial infections practices is recommended.
PMCID: PMC3768458  PMID: 24031278
Nosocomial infection; epidemiology; multiresistant microorganisms
19.  Tigecycline in the treatment of complicated intra-abdominal and complicated skin and skin structure infections 
Tigecycline, a glycylcycline related to the tetracycline class of antibiotics, represents a new option for the treatment of complicated intra-abdominal and complicated skin and skin structure infections. It displays favorable activity in vitro against the most common causative Gram-positive, Gram-negative and anaerobic pathogens. In addition, tigecycline demonstrates activity against drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and organisms (such as Escherichia coli and Klebsiella pneumoniae) producing extended-spectrum beta-lactamases. Tigecycline lacks activity in vitro against Pseudomonas and Proteus spp. In randomized clinical trials, tigecycline administered intravenously twice daily has demonstrated efficacy similar to comparators for a variety of complicated skin and skin structure and complicated intra-abdominal infections. The potential for significant drug interactions with tigecycline appears to be minimal. Dosing adjustment is needed for patients with severe hepatic impairment. The predominant side effect associated with its use to date has been gastrointestinal intolerance (nausea and vomiting).
PMCID: PMC2387284  PMID: 18516315
tigecycline; intra-abdominal infections; complicated skin and skin structure infections
20.  Outcome of infections due to pandrug-resistant (PDR) Gram-negative bacteria 
The increasing problem of infections due to multidrug-resistant Gram-negative bacteria has led to re-use of polymyxins in several countries. However, there are already clinical isolates of Gram-negative bacteria that are resistant to all available antibiotics, including polymyxins.
We present a case series of patients with infections due to pathogens resistant to all antimicrobial agents tested, including polymyxins. An isolate was defined as pandrug-resistant (PDR) if it exhibited resistance to all 7 anti-pseudomonal antimicrobial agents, i.e. antipseudomonal penicillins, cephalosporins, carbapenems, monobactams, quinolones, aminoglycosides, and polymyxins.
Clinical cure of the infection due to pandrug-resistant (PDR) Gram-negative bacteria, namely Pseudomonas aeruginosa or Klebsiella pneumoniae was observed in 4 out of 6 patients with combination of colistin and beta lactam antibiotics.
Colistin, in combination with beta lactam antibiotics, may be a useful agent for the management of pandrug-resistant Gram-negative bacterial infections. The re-use of polymyxins, an old class of antibiotics, should be done with caution in an attempt to delay the rate of development of pandrug-resistant Gram-negative bacterial infections.
PMCID: PMC1087841  PMID: 15819983
21.  Nosocomial Outbreak Due to Extended-Spectrum-Beta-Lactamase- Producing Enterobacter cloacae in a Cardiothoracic Intensive Care Unit▿  
Journal of Clinical Microbiology  2007;45(8):2365-2369.
Enterobacter cloacae has been associated with several outbreaks, usually involving strains that overproduce chromosomal β-lactamase or, uncommonly, strains expressing extended-spectrum β-lactamases (ESBL). Only sporadic cases of ESBL-producing E. cloacae have been identified in our hospital in recent years. We describe the epidemiology and clinical and microbiological characteristics of an outbreak caused by ESBL-producing E. cloacae in a cardiothoracic intensive care unit (CT-ICU). Prospective surveillance of patients with infection or colonization by ESBL-producing E. cloacae among patients admitted to the CT-ICU was performed during the outbreak. Production of ESBL was determined by decreased susceptibility to expanded-spectrum cephalosporins and a positive double-disk test result. Clone relatedness was determined by pulsed-field gel electrophoresis (PFGE). From July to September 2005, seven patients in the CT-ICU with ESBL-producing E. cloacae were identified (four males; median age, 73 years; range, 45 to 76 years); six patients had cardiac surgery. Four patients developed infections; three had primary bacteremia, one had ventilator-associated pneumonia, and one had tracheobronchitis. ESBL-producing E. cloacae showed resistance to quinolones and aminoglycosides. PFGE revealed two patterns. Five isolates belonged to clone A; two carried a single ESBL (pI 8.2 and a positive PCR result for the SHV type), and three carried two ESBLs (pIs 8.1 and 8.2 and positive PCR results for the SHV and CTX-M-9 types). Isolates belonging to clone B carried a single ESBL (pI 5.4 and a positive PCR result for the TEM type). Review of antibiotic consumption showed increased use of cefepime and quinolones during June and July 2005. The outbreak was stopped by the implementation of barrier measures and cephalosporin restriction. ESBL production could be increasingly common in nosocomial pathogens other than Escherichia coli or Klebsiella pneumoniae.
PMCID: PMC1951272  PMID: 17581932
22.  Risk Factors Associated with Vancomycin-Resistant Enterococcus in Intensive Care Unit Settings in Saudi Arabia 
Background. Vancomycin-resistant enterococci (VRE) are significant nosocomial pathogens worldwide. There is one report about the epidemiology of VRE in Saudi Arabia. Objective. To determine the risk factors associated with VRE infection or colonization in intensive care unit (ICU) settings. Design. This is a descriptive, epidemiologic hospital-based case-control study of patients with VRE from February 2006 to March 2010 in ICU in a tertiary hospital in Saudi Arabia. Methods. Data were collected from hospital records of patients with VRE. The main outcome measure was the adjusted odds ratio estimates of potential risk factors for VRE. Results. Factors associated with VRE included ICU admission for multiorgan failure, chronic renal failure, prior use of antimicrobial agents in the past three months and before ICU admission, gastrointestinal oral contrast procedure, and hemodialysis. Being located in a high risk room (roommate of patients colonized or infected with VRE) was found to be protective. Conclusions. Factors associated with VRE acquisition are often complex and may be confounded by local variables.
PMCID: PMC3762139  PMID: 24027580
23.  Additional risk factors for infection by multidrug-resistant pathogens in healthcare-associated infection: a large cohort study 
BMC Infectious Diseases  2012;12:375.
There is a lack of consensus regarding the definition of risk factors for healthcare-associated infection (HCAI). The purpose of this study was to identify additional risk factors for HCAI, which are not included in the current definition of HCAI, associated with infection by multidrug-resistant (MDR) pathogens, in all hospitalized infected patients from the community.
This 1-year prospective cohort study included all patients with infection admitted to a large, tertiary care, university hospital. Risk factors not included in the HCAI definition, and independently associated with MDR pathogen infection, namely MDR Gram-negative (MDR-GN) and ESKAPE microorganisms (vancomycin-resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus, extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species, carbapenem-hydrolyzing Klebsiella pneumonia and MDR Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species), were identified by logistic regression among patients admitted from the community (either with community-acquired or HCAI).
There were 1035 patients with infection, 718 from the community. Of these, 439 (61%) had microbiologic documentation; 123 were MDR (28%). Among MDR: 104 (85%) had MDR-GN and 41 (33%) had an ESKAPE infection. Independent risk factors associated with MDR and MDR-GN infection were: age (adjusted odds ratio (OR) = 1.7 and 1.5, p = 0.001 and p = 0.009, respectively), and hospitalization in the previous year (between 4 and 12 months previously) (adjusted OR = 2.0 and 1,7, p = 0.008 and p = 0.048, respectively). Infection by pathogens from the ESKAPE group was independently associated with previous antibiotic therapy (adjusted OR = 7.2, p < 0.001) and a Karnofsky index <70 (adjusted OR = 3.7, p = 0.003). Patients with infection by MDR, MDR-GN and pathogens from the ESKAPE group had significantly higher rates of inadequate antibiotic therapy than those without (46% vs 7%, 44% vs 10%, 61% vs 15%, respectively, p < 0.001).
This study suggests that the inclusion of additional risk factors in the current definition of HCAI for MDR pathogen infection, namely age >60 years, Karnofsky index <70, hospitalization in the previous year, and previous antibiotic therapy, may be clinically beneficial for early diagnosis, which may decrease the rate of inadequate antibiotic therapy among these patients.
PMCID: PMC3566942  PMID: 23267668
Healthcare-associated infections; Multidrug resistant pathogens infection; Multidrug resistant gram negatives infection; ESKAPE microorganisms’ infection; Independent risk factors; Inadequate antibiotic therapy
24.  Extended Spectrum Beta-lactamase Detection in Gram-negative Bacilli of Nosocomial Origin 
Resistance to third generation cephalosporins by acquisition and expression of extended spectrum beta lactamase (ESBL) enzymes among gram-negative bacilli is on a rise. The presence of ESBL producing organisms significantly affects the course and outcome of an infection and poses a challenge to infection management worldwide.
Materials and Methods:
In the period from June 2007 to 2008, we collected 1489 samples from patients suspected of nosocomial infection. The isolates were identified based on colony morphology and biochemical reaction. Gram negative bacilli resistant to third generation cephalosporins were tested for ESBL by double disc synergy test (DDST- a screening test)and then phenotypic confirmatory test. Antimicrobial susceptibility testing was done by modified Kirby Bauer disc diffusion method.
From the sample of 238 gram-negative bacilli, we isolated Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Citrobacter freundii, Proteus mirabilis, Morganella morganii and Enterobacter cloacae. Following both methods, 34% isolates were ESBL-positive. The ESBL producing isolates were significantly resistant (p < 0.01) to ampicillin, piperacillin, piperacillin/tazobactam, trimethoprim/sulfamethoxazole, tetracycline, ciprofloxacin and gentamicin as compared to non-ESBL producers. Multidrug resistance was significantly (p < 0.01) higher (69.14%) in ESBL positive isolates than non-ESBL isolates (21.66%).
High prevalence of ESBL in our hospital cannot be ignored. ESBL producers can be detected by DDST and phenotypic confirmatory test with equal efficacy. The sensitivity of screening test improved with the use of more than one antibiotic and addition of one or two antibiotics would not increase cost and labor. We recommend DDST using multiple antibiotics in all microbiology units as a routine screening test.
PMCID: PMC2840957  PMID: 20300397
ESBL; Gram negative bacilli; Nosocomial
25.  Changing carbapenemase gene pattern in an epidemic multidrug-resistant Acinetobacter baumannii lineage causing multiple outbreaks in central Italy 
Infections caused by multidrug-resistant (MDR) Acinetobacter baumannii are a challenging problem worldwide. Here, the molecular epidemiology and the genetic basis of antibiotic resistance in 111 MDR A. baumannii strains isolated from June 2005 to March 2009 from infected patients in 10 intensive care units (ICUs) in central Italy were investigated.
Epidemiological typing was performed by random amplification of polymorphic DNA, PCR-based sequence grouping and macrorestriction analysis. MICs of antibiotics were determined by the broth microdilution method. Genes for OXA carbapenemases, metallo-β-lactamases and the CarO porin were searched for by PCR.
Molecular genotyping identified one predominant A. baumannii lineage, related to the international clonal lineage II, accounting for 95.6% of isolates. Isolates referable to this lineage were recovered from all ICUs surveyed and were resistant to nearly all classes of antimicrobials, with the exception of tigecycline and colistin. A high percentage (60.5%) of A. baumannii isolates showed elevated resistance to imipenem (MICs ≥ 128 mg/L), concomitant with resistance to meropenem. Carbapenem resistance was associated with the presence of either blaOXA-58-like (22.8%) or blaOXA-23-like (71.1%) carbapenemase genes. Molecular typing showed that the epidemic lineage encoding OXA-23 emerged in 2007 and displaced a genetically related clone encoding OXA-58 that had been responsible for previous ICU outbreaks in the same region.
Emergence of the OXA-23 epidemic lineage could result from selective advantage conferred by the blaOXA-23-like determinant, which provides increased resistance to carbapenems.
PMCID: PMC3031335  PMID: 21088019
genotyping; intensive care units; OXA-23

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