The incidence and prevalence of hospital-acquired (carbapenem-resistant) Acinetobacter baumannii in Europe, Eastern Mediterranean and Africa: a systematic review and meta-analysis.
ABSTRACT: Due to therapeutic challenges, hospital-acquired infections (HAIs) caused by Acinetobacter baumannii (HA-AB), particularly carbapenem-resistant strains (HA-CRAB) pose a serious health threat to patients worldwide. This systematic review sought to summarize recent data on the incidence and prevalence of HA-AB and HA-CRAB infections in the WHO-defined regions of Europe (EUR), Eastern Mediterranean (EMR) and Africa (AFR). A comprehensive literature search was performed using MEDLINE, EMBASE and GMI databases (01/2014-02/2019). Random-effects meta-analyses were performed to determine the pooled incidence of HA-AB and HA-CRAB infections as well as the proportions of A. baumannii among all HAIs. 24 studies from 3,340 records were included in this review (EUR: 16, EMR: 6, AFR: 2). The pooled estimates of incidence and incidence density of HA-AB infection in intensive care units (ICUs) were 56.5 (95% CI 33.9-92.8) cases per 1,000 patients and 4.4 (95% CI 2.9-6.6) cases per 1,000 patient days, respectively. Five studies conducted at a hospital-wide level or in specialized clinical departments/wards (ICU + non-ICU patients) showed HA-AB incidences between 0.85 and 5.6 cases per 1,000 patients. For carbapenem-resistant A. baumannii infections in ICUs, the pooled incidence and incidence density were 41.7 (95% CI 21.6-78.7) cases per 1,000 patients and 2.1 (95% CI 1.2-3.7) cases per 1,000 patient days, respectively. In ICUs, A. baumannii and carbapenem-resistant A. baumannii strains accounted for 20.9% (95% CI 16.5-26.2%) and 13.6% (95% CI 9.7-18.7%) of all HAIs, respectively. Our study highlights the persistent clinical significance of hospital-acquired A. baumannii infections in the studied WHO regions, particularly in ICUs.
Project description:<h4>Background</h4>Active surveillance has the potential to prevent nosocomial transmission of carbapenem-resistant <i>Acinetobacter baumannii</i> (CRAB). We assessed whether rapid diagnosis using clinical specimen-direct loop-mediated isothermal amplification (LAMP), a rapid molecular diagnostic assay, and subsequent intervention, could reduce CRAB nosocomial transmission in intensive care units (ICUs).<h4>Methods</h4>A before and after (quasi-experimental) study was conducted in two ICUs at the Mahidol University Faculty of Medicine Ramathibodi Hospital with 3?months of observational period followed by 9?months of interventional period. All patients were screened for CRAB using both the culture and LAMP method from rectal swab and/or bronchial aspirates (intubated patients only) upon admission, weekly thereafter, and upon discharge. During the pre-intervention period, we performed contact precautions based on culture results. In contrast, during the intervention period, we initiated contact precautions within a few hours after sample collection on the basis of LAMP results.<h4>Results</h4>A total of 1335 patients were admitted to the ICUs, of which 866 patients (pre-intervention period: 187; intervention period: 679) were eligible for this study. Incidence rate of CRAB infection decreased to 20.9 per 1000 patient-days in the intervention period from 35.2 in the pre-intervention period (<i>P</i>?<?0.02). The calculated hazard ratio of CRAB transmission was 0.65 (95% confidence interval [CI], 0.44-0.97). Risk factors for CRAB acquisition included exposure to carbapenem (hazard ratio, 2.54 [95% CI: 1.61-5.57]).<h4>Conclusions</h4>LAMP screening for CRAB upon ICU admission proved feasible for routine clinical practice. Rapid screening using LAMP followed by early intervention may reduce CRAB transmission rates in ICUs when compared to conventional intervention.
Project description:<i>Acinetobacter baumannii</i> is one of the key Gram-negative pathogens that can cause serious nosocomial infections. In China, a large proportion of clinical <i>A. baumannii</i> strains are multidrug resistant, among which strains resistant to carbapenems are particularly worrisome, as infections caused by such strains may limit the choice of existing antibiotics. We conducted a nationwide and genome-based surveillance on the prevalence and antibiotic susceptibility profile of carbapenem-resistant <i>A. baumannii</i> (CRAB) strains collected from intensive care units (ICUs) in hospitals in different provinces and investigated the routes of transmission and mechanism of resistance by whole-genome sequencing and phylogenetic analysis. We found that CRAB strains were prevalent in 71.4% (55/77) of the ICUs surveyed. Clonal spread of CRAB was found in 37.6% (29/77) of ICUs and a total of 22 different clones were identified. Most clones were transmissible within one ICU, but up to six clones could be detected in at least three hospitals. In addition, carbapenem-hydrolysing class D β-lactamases (CHDL) were found to be mainly responsible for carbapenem-resistance in <i>A. baumannii</i> and the ST2 global-clone is the predominant type of CRAB in China. Importantly, we found that CRAB isolates currently exhibited an extremely low rate of resistance to colistin (0.4%) and tigecycline (2.5%), but a high rate of resistance to ceftazidime-avibactam (70.2%). Findings in this work shall facilitate development of appropriate antimicrobial regimens for treatment of CRAB infections. Further surveillance and research on the evolutionary and epidemiological features of clinical CRAB strains are necessary.
Project description:BACKGROUND:Vietnam is a lower middle-income country with no national surveillance system for hospital-acquired infections (HAIs). We assessed the prevalence of hospital-acquired infections and antimicrobial use in adult intensive care units (ICUs) across Vietnam. METHODS:Monthly repeated point prevalence surveys were systematically conducted to assess HAI prevalence and antimicrobial use in 15 adult ICUs across Vietnam. Adults admitted to participating ICUs before 08:00 a.m. on the survey day were included. RESULTS:Among 3287 patients enrolled, the HAI prevalence was 29.5% (965/3266 patients, 21 missing). Pneumonia accounted for 79.4% (804/1012) of HAIs Most HAIs (84.5% [855/1012]) were acquired in the survey hospital with 42.5% (363/855) acquired prior to ICU admission and 57.5% (492/855) developed during ICU admission. In multivariate analysis, the strongest risk factors for HAI acquired in ICU were: intubation (OR 2.76), urinary catheter (OR 2.12), no involvement of a family member in patient care (OR 1.94), and surgery after admission (OR 1.66). 726 bacterial isolates were cultured from 622/1012 HAIs, most frequently Acinetobacter baumannii (177/726 [24.4%]), Pseudomonas aeruginosa (100/726 [13.8%]), and Klebsiella pneumoniae (84/726 [11.6%]), with carbapenem resistance rates of 89.2%, 55.7%, and 14.9% respectively. Antimicrobials were prescribed for 84.8% (2787/3287) patients, with 73.7% of patients receiving two or more. The most common antimicrobial groups were third generation cephalosporins, fluoroquinolones, and carbapenems (20.1%, 19.4%, and 14.1% of total antimicrobials, respectively). CONCLUSION:A high prevalence of HAIs was observed, mainly caused by Gram-negative bacteria with high carbapenem resistance rates. This in combination with a high rate of antimicrobial use illustrates the urgent need to improve rational antimicrobial use and infection control efforts.
Project description:<i>Acinetobacter baumannii</i> emerged as one of the most important pathogens that causes nosocomial infections due to its increased multidrug resistance. Identifying capsular epidemiology in <i>A. baumannii</i> can aid in the development of effective treatments and preventive measures against this emerging pathogen. Here we established a <i>wzc</i>-based method, and combined it with <i>wzy</i>-PCR to determine capsular types of <i>A. baumannii</i> causing nosocomial bacteraemia collected at two medical centres in Taiwan from 2015 to 2017. Among the 237 patients with <i>A. baumannii</i> bacteraemia, 98 (41.4%) isolates were resistant to carbapenems. Four prevalent capsular types (KL2, KL10, KL22, and KL52) accounted for 84.7% of carbapenem-resistant <i>A. baumannii</i> (CRAB) and 12.2% of non-CRAB. The rate of pneumonia, intensive care unit admission, APACHE II score, and Pitt bacteraemia score were higher in patients with KL2/10/22/52 infection than in those with non-KL2/10/22/52 infection. Patients with KL2/10/22/52 infection and patients with CRAB infection have a higher cumulative incidence of attributable and all-cause in-hospital 30-day mortality. On multivariate analysis, appropriate empirical antimicrobial therapy within 24 h was associated with a lower risk of 30-day attributable mortality in the KL2/10/22/52 isolates (odds ratio = 0.19, 95% CI: 0.06-0.66, <i>p</i> = 0.008) but not in non-KL2/10/22/52 isolates. Early recognition of carbapenem resistance-associated capsular types may help clinicians to promptly implement appropriate antimicrobial therapy for improving the outcomes in patients with CRAB bacteraemia.
Project description:The incidence density trend of the carbapenem-resistant Gram-negative bacteria was analysed in device-associated infections and antimicrobial consumption in 99 critical care facilities in a low/middle-income country, between January 2019 and December 2020. Carbapenem-resistant Acinetobacter baumannii (CRAB) per 1000 patient-days increased in 2020 and this finding had a strong positive correlation with the incidence density of COVID-19 by the Spearman test. Polymyxin consumption also increased in 2020 but without significant correlation with CRAB or COVID-19 incidence density, presumably due to empirical and untargeted prescribing as a consequence of concern about CRAB infections. These findings are a warning to infection control programmes and antimicrobial stewardship.
Project description:BACKGROUND:Available data on antibiotic resistance in sub-Saharan Africa is limited despite its increasing threat to global public health. As there is no previous study on antibiotic resistance in patients with clinical features of healthcare-associated infections (HAIs) in Sierra Leone, research is needed to inform public health policies. Our study aimed to assess antibiotic resistance rates from isolates in the urine and sputum samples of patients with clinical features of HAIs. METHODOLOGY:We conducted a cross-sectional study of adult inpatients aged ?18?years at Connaught Hospital, an urban tertiary care hospital in Freetown between February and June 2018. RESULTS:Over the course of the study, we enrolled 164 patients. Risk factors for HAIs were previous antibiotic use (93.3%), comorbidities (58.5%) and age (?65?years) (23.9%). Of the 164 samples, 89.6% were urine. Bacterial growth was recorded in 58.8% of cultured specimens; the type of specimen was an independent predictor of bacterial growth (p?<?0.021). The most common isolates were Escherichia coli and Klebsiella pneumoniae; 29.2% and 19.0% in urine samples and 18.8% and 31.3% in sputum samples, respectively. The overall resistance rates were 58% for all extended-spectrum beta-lactamase (ESBL)-producing organisms, 13.4% for carbapenem-resistant non-lactose fermenting gram-negative bacilli, 8.7% for carbapenem-resistant Acinetobacter baumannii (CRAB) and 1.3% for carbapenem-resistant Enterobacteriaceae (CRE). There were no carbapenem-resistant P. aeruginosa (CRPA) isolates but all Staphylococcus aureus isolates were methicillin-resistant S. aureus. CONCLUSION:We demonstrated a high prevalence rate of ESBL-producing organisms which are a significant burden at the main tertiary hospital in Sierra Leone. Urgent action is needed to strengthen microbiological diagnostic infrastructure, initiate surveillance on antibiotic resistance and develop and implement policy framework on antibiotic stewardship.
Project description:The role of carbapenem-resistant Acinetobacter baumannii (CRAb) in polymicrobial infection remains elusive. Having observed the ability of CRAb to shelter other susceptible bacteria from carbapenem killing, we sought to determine the factors contributing to this sheltering effect by transforming different recombinant plasmids into recipient A. baumannii cells. The sheltering effects of CRAb were reproduced in recipient A. baumannii cells that highly expressed carbapenem-hydrolyzing class D ?-lactamases (CHDLs) through their associated strong promoter. With the use of Western blot analysis and a bioassay, the highly expressed CHDLs were found to be extracellularly released and led to hydrolysis of carbapenem. The level of extracellular CHDLs increased after challenge with a higher concentration of CHDL substrates, such as carbapenem and ticarcillin. This increased CHDL may, in part, be attributed to cell lysis, as indicated by the presence of extracellular gyrase. In the planktonic condition, the sheltering effect for the cocultured susceptible bacteria might represent an indirect and passive effect of the CRAb self-defense mechanism, because coculture with the susceptible pathogen did not augment the amount of the extracellular CHDLs. Polymicrobial infection caused by CRAb and a susceptible counterpart exerted higher pathogenicity than monomicrobial infection caused by either pathogen alone in mice receiving carbapenem therapy. This study demonstrated that CHDL-producing CRAb appears to provide a sheltering effect for carbapenem-susceptible pathogens via the extracellular release of CHDLs and, by this mechanism, can enhance the pathogenesis of polymicrobial infection in the presence of carbapenem therapy.
Project description:There is scarce information regarding hospital-acquired infections (HAIs) among children in resource-constrained settings. This study aims to measure prevalence of HAIs in Vietnamese pediatric hospitals.Monthly point prevalence surveys (PPSs) in 6 pediatric intensive care units (ICUs) in 3 referral hospitals during 1 year.A total of 1363 cases (1143 children) were surveyed, 59.9% male, average age 11 months. Admission sources were: other hospital 49.3%, current hospital 36.5%, and community 15.3%. Reasons for admission were: infectious disease (66%), noninfectious (20.8%), and surgery/trauma (11.3%). Intubation rate was 47.8%, central venous catheter 29.4%, peripheral venous catheter 86.2%, urinary catheter 14.6%, and hemodialysis/filtration 1.7%. HAI was diagnosed in 33.1% of the cases: pneumonia (52.2%), septicemia (26.4%), surgical site infection (2%), and necrotizing enterocolitis (2%). Significant risk factors for HAI included age under 7 months, intubation and infection at admission. Microbiological findings were reported in 212 cases (43%) with 276 isolates: 50 Klebsiella pneumoniae, 46 Pseudomonas aeruginosa, and 39 Acinetobacter baumannii, with carbapenem resistance detected in 55%, 71%, and 65%, respectively. Staphylococcus aureus was cultured in 18 cases, with 81% methicillin-resistant Staphylococcus aureus. Most children (87.6%) received antibiotics, with an average of 1.6 antibiotics per case. Colistin was administered to 96 patients, 93% with HAI and 49% with culture confirmed carbapenem resistance.The high prevalence of HAI with carbapenem resistant gram-negative strains and common treatment with broad-spectrum antibiotics and colistin suggests that interventions are needed to prevent HAI and to optimize antibiotic use.
Project description:OBJECTIVES:To assess the incidence and the impact of carbapenem-resistant Acinetobacter baumannii (CRAB) intestinal carriage on subsequent CRAB infection and to study risk factors of acquiring CRAB intestinal carriage among patients in intensive care unit (ICU). DESIGN:Observational study including a case-control study and a retrospective cohort study. SETTING:A 50-bed general ICU of a university hospital, China. METHODS:From May 2017 to April 2018, an observational study was conducted in a 50-bed general ICU of a university hospital in China. Rectal swabs were collected from ICU patients on admission and thereafter weekly. A case-control study was performed to analyse risk factors of the acquisition of CRAB intestinal carriage in ICU using multiple logistic regression. A retrospective cohort study was performed to address whether intestinal CRAB carriage could lead to an increased likelihood of subsequent CRAB infection using subdistribution hazard model regarding death in the ICU as a competing risk event. RESULTS:CRAB intestinal carriage was detected in 6.87% (66/961; 95%?CI 5.27% to 8.47%) of patients on ICU admission, whereas 11.97% (115/961; 95%?CI 9.91% to 14.02%) of patients acquired CRAB intestinal carriage during the ICU stay. Pancreatitis (OR 2.16, 95%?CI 1.28 to 3.67), haematological disease (OR 2.26, 95%?CI 1.42 to 3.58), gastric tube feeding (OR 3.35, 95%?CI 2.03 to 5.51) and use of carbapenems (OR 1.84, 95%?CI 1.11 to 3.07) were independent risk factors for acquiring CRAB intestinal carriage. The incidence of subsequent CRAB infection was 2.24-fold in patients with CRAB intestinal carriage compared with that in patients without (95%?CI 1.48 to 3.39, p<0.001). CONCLUSION:More patients acquired CRAB intestinal carriage during their ICU stay than had on admission. Severity of illness, acute pancreatitis, tube feeding and use of carbapenems were independent risk factors of acquisition of CRAB intestinal carriage. Patients with CRAB intestinal carriage are more likely to develop CRAB infection.
Project description:Background:Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex have emerged worldwide, but the epidemiology in Indonesian hospitals has not been studied. Methods:A prospective observational study was performed on the intensive care units (ICUs) of the national referral hospital in Jakarta-Indonesia, in 2013 and 2014. All consecutive adult patients admitted and hospitalized for >48 h in ICUs were included. Basic and clinical data at admission were recorded. Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex from clinical cultures and standardized screening were included. Environmental niches and healthcare workers (HCWs) were also screened. PCR was used to detect carbapenemase genes, and Raman spectroscopy as well as multilocus sequence typing (MLST) for typing. Results:Of 412 included patients, 69 (16.7%) carried carbapenem-nonsusceptible A. baumannii-calcoaceticus complex on admission, and 89 (25.9%) became positive during ICU stay. The acquisition rate was 43 per 1000 patient-days at risk. Six isolates were cultured from environment and one from a HCW. Acquisition of carbapenem-nonsusceptible A. baumannii-calcoaceticus complex was associated with longer ICU stay (median interquartile range [IQR]: 11 days [5-18], adjusted hazard ratio [aHR]: 2.56 [99% confidence interval (CI):1.76-3.70]), but not with mortality (adjusted odds ratio: 1.59 [99%CI: 0.74-3.40] at the chosen level of significance). The blaOXA-23-like gene was detected in 292/318 (91.8%) isolates, including isolates from the environment and HCW. Typing revealed five major clusters. Sequence types (ST)195, ST208, ST218, ST642 as well as new STs were found. The dominant clone consisted of isolates from patients and environment throughout the study period. Conclusions:Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex are endemic in this setting. Prevention requires source control and limiting transmission of strains. Trial registration:The study was retrospectively registered at www.trialregister.nl (No:5541). Candidate number: 23,527, NTR number: NTR5541, Date registered NTR: 22nd December 2015.