Infection Control & Hospital Epidemiology
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Fig. 1. Full and intermediate resistance rates for the panel of antibiotics against 92 multidrug-resistant organisms, except carbapenemase producers, recovered during the study period.
Amikacin and ertapenem demonstrated the most reliable in vitro
activity, with susceptibility rates of 89.2% and 87% in tested isolates, respectively, while gentamicin showed only a reasonable activity (68.5% of susceptibility). Trimethoprim/sulfamethoxazole and ciprofloxacin presented a high resistance rate (>60%), and ceftriaxone (aswell asanother β-lactams [data not shown]) was themost affected agent (Figure 1). Among the KPC producers, in vitro susceptibility was observed only to amikacin (100%) and gentamicin (54.5%). ESBL-producing organisms were the most prevalent in this
survey, and they are frequently resistant to multiple antimicrobial agents, which greatly limits therapeutic options.3,6 Currently, car- bapenems are recommended for the treatment of serious infections caused by ESBL-producing organisms. On the other hand, addi- tional data on ESBL incidence and risk factors for infection and/or colonization are needed to better establish the use of carbapenems. Notably, carbapenem-resistance has also emerged in the community by KPC producers and non-carbapenemase producers.2,3,5,7 In this study, ertapenem-resistance was observed only among Enterobacter spp isolates. As reported elsewhere,8,9 Enterobacter spp have emerged as an important nosocomial MDR threat. Its presence in the community underscores the need for more comprehensive surveillance to curb spreading.7,9 This study has some limitations. First, the isolates identified
were categorized as community acquired. Data on prior health care exposures that may have preceded the current admission from community were not fully available. The distinction between colonization and infection is quite difficult, especially in older patients. A second limitation is inherent in the use of urinary samples for surveillance purposes, which may underestimate the findings of a real colonization. Also, this was a surveillance study, and the genetic backgrounds of the isolates were not evaluated. Notably, some patients may have had prior healthcare or long-
previously published data,2,3 ESBL-producing E. coli strains are a notable cause of community infection and/or colonization in predisposed patients. However, the presence of Enterobacter spp. (mainly Enterobacter cloacae complex) with ertapenem-resistance phenotype and KPC-producing Klebsiella pneumoniae illustrate the complexity of resistance mechanisms emerging in settings
term care exposure but were admitted from community during the study period. Although the distinction between community and nosocomial patients is increasingly complex, this survey has important implications for hospitals that screen patients for MDR organisms upon admission. In conclusion, these results confirm that, in concordance with
other than the hospital. There is an urgent need to design stew- ardship programs and infection control efforts involving not only nosocomial but also community strategies against multidrug resistance. Our findings need to be validated in other independent studies to further our understanding of the community epide- miology of MDR isolates.
Acknowledgments. The author is grateful to the staff of Microbiology Unit at Hospital Mãe de Deus for technical support.
Financial support. No financial support was provided relevant to this article.
Potential conflicts of interest. The author reports no conflicts of interest relevant to this article.
References
1. van Duin D, Kaye KS, Neuner EA, et al. Carbapenem-resistant Enterobacter- iaceae: a review of treatment and outcomes. Diagn Microbiol Infect Dis 2013;75:115–120.
2. Laupland KB, Ross T, Pitout JDD, Church DL, Gregson DB. Community- onset urinary tract infections: a population-based assessment. Infection 2007;35:150–153.
3. Manges AR, Dietrich PS, Riley LW. Multidrug-resistant Escherichia coli clonal groups causing community-acquired pyelonephritis. Clin Infect Dis 2004;38:329–334.
4. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing: twenty-second informational supplement M100-S22. Wayne, PA: CLSI; 2012.
5. Perez LR. Is the polymyxin B resistance among multidrug-resistant Enterobacteriaceae (except for the carbapenemase-producing ones) a myth or a matter? Infect Control Hosp Epidemiol 2017;38:126–127.
6. Perez LRR, Narvaez GA. Understanding the β-lactam/inhibitor of β-lactamase combinations: reassessment for better antimicrobial steward- ship. Infect Control Hosp Epidemiol 2017;38:881–883.
7. Perez LR. Does second place count? Lessons from a major discrepancy between carbapenem-resistant Klebsiella pneumoniae and carbapenem- resistant Enterobacter cloacae in a one-year follow-up study. Infect Control Hosp Epidemiol 2017;38:632–634.
8. Rodrigues Perez LR. Carbapenem-resistant Enterobacteriaceae: a major prevalence difference due to the high performance of carbapenemase producers when compared to the nonproducers. Infect Control Hosp Epidemiol 2015;36:1480–1482.
9. Perez LRR. From dusk to dawn: understanding the impact of ertapenem resistance mechanisms on the in vitro potency of other drugs among Enterobacter cloacae complex isolates. Infect Control Hosp Epidemiol 2018; 39:500–502.
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