Trends in HIV surveillance data in the EU/EEA, 2005 to 2014: New HIV diagnoses still increasing in men who have sex with men

Human immunodeficiency virus (HIV) transmission remains significant in Europe. Rates of acquired immunodeficiency syndrome (AIDS) have declined, but not in all countries. New HIV diagnoses have increased among native and foreign-born men who have sex with men. Median CD4+T-cell count at diagnosis has increased, but not in all groups, and late diagnosis remains common. HIV infection and AIDS can be eliminated in Europe with resolute prevention measures, early diagnosis and access to effective treatment

Risk factors for colonization or infection with methicillin-resistant staphylococcus aureus (MRSA) in surgical patients

Considering that MRSA colonization predisposes to subsequent surgical siteinfections, with often disastrous consequences, it was decided to determine theprevelance of MRSA carriage at admission to the hospital, to identify the potential riskfactors for colonization with MRSA and to determine the phenotypic and genotypiccharacteristics of the isolates. Consecutive patients admitted to three surgical units of a tertiary care hospital in Athens, between January-July 2009, were screened within48h of admission and weekly thereafter for MRSA carriage. The nares and inguinalarea were sampled with a sterile swab, and samples were inoculated onto BBLTMCHROMagarTM MRSA II medium. Susceptibilities to commonly used antimicrobialswere determined by Kirby-Bauer disk-diffusion method. Isolates were classified aseither CA-MRSA or HA-MRSA, according to CDC epidemiologic definition. All MRSAisolates were examined for the presence of Panton-Valentine leukocidin (PVL) andmecA genes, and classified according to SCCmec type. Spa typing and multilocussequence typing (MLST) were performed for a selected number of isolates. A total of925 patients (51% males; median age, 62.8 years) were screened, of whom 51(5.51%) were positive for MRSA at the time of admission, and sixteen acquired MRSAcolonization during hospitalization. Hospitalization during the past 12 months (OR:2.52 , 95%CI:1.30-4.88 , P: 0.006), diabetes mellitus (OR: 3.13 , 95%CI:1.60-6.13 , P:0.001), nursing home residency (OR: 26.46, 95%CI: 4.37-160.15 , P: <0.001), chronicskin disease (OR: 2.82 , 95%CI:1.17-6.81 , P: 0.021) and antibiotic treatment in theprevious 6 months (OR: 2.02 , 95%CI:1.05-3.90 , P:0.036) were independent risk factors for MRSA carriage at admission. Fifteen (29.41%) of 51 MRSA isolates fulfilledthe epidemiologic criteria for CA-MRSA of which 9 belonged to community MRSAclones and 6 to hospital MRSA clones. The community clones were ST80-IVc (n=7)and ST30-IVc (n=2), whereas the hospital clones were ST239-III, ST5-II, ST105-IIand ST22-IVc. Of 36 HA-MRSA isolates, as designated by epidemiologic criteria, 7 ofthe 8 PVL-positive isolates that were analyzed belonged to the community MRSAclone, ST80-IVc. Four of the 14 PVL-positive isolates of the ST80-IVc genetic lineageexhibited resistance to ≥ 3 non-β-lactam classes of antibiotics. Five colonized (7.46%)patients developed infections. These patients developed infections with their owncolonizing strains. Most infections were caused by CA-MRSA clones. In conclusion,colonization with MRSA is common in patients with previous hospitalization, antibioticuse, nursing home residency, diabetes mellitus and chronic skin disease. Thechanging epidemiology of MRSA has led to the mixing of CA- with HA-MRSA clonesin both the hospital and community settings. Furthermore, a significant proportion ofthe MRSA colonizing surgical patients in our geographic region belongs to the epidemiologically successful ST80-IVc European clone which has the potential to become multidrug resistant and cause nosocomial infections.Έχοντας ως δεδομένο ότι η φορεία MRSA προδιαθέτει σε ανάπτυξη χειρουργικώνλοιμώξεων, συχνά με καταστροφικές συνέπειες, πραγματοποιήθηκε η παρούσαμελέτη με σκοπό να προσδιοριστεί ο επιπολασμός της φορείας MRSA κατά τηνεισαγωγή των ασθενών στις χειρουργικές κλινικές, να αναζητηθούν οι παράγοντεςκινδύνου για αποικισμό και να προσδιοριστούν τα φαινοτυπικά και γονοτυπικάχαρακτηριστικά των απομονωθέντων στελεχών. Η μελέτη πραγματοποιήθηκε σε τρειςχειρουργικές κλινικές ενός τριτοβάθμιου νοσοκομείου της Αθήνας μεταξύ Ιανουαρίου-Ιουλίου του 2009. Καλλιέργειες για φορεία MRSA (ρώθωνες, περίνεο) λαμβάνονταναπό όλους τους ασθενείς εντός 48 ωρών από την εισαγωγή και εβδομαδιαίως. Ταδείγματα ενοφθαλμίζονταν στο χρωμογόνο καλλιεργητικό υλικό BBLTMCHROMagarTM MRSA II. Οι ευαισθησίες των στελεχών προσδιοριστήκαν με τημέθοδο διάχυσης των δίσκων κατά Kirby-Bauer. Τα στελέχη ταξινομήθηκαν είτε ωςCA-MRSA ή HA-MRSA, σύμφωνα με τον επιδημιολογικό ορισμό του CDC. Όλα ταMRSA στελέχη εξετάστηκαν για την παρουσία των γονιδίων της Panton-Valentineλευκοκτονίνης (lukF-PV , lukS-PV) και του γονιδίου mecA, και ταξινομήθηκαν με βάση τους τύπους SCCmec. Συγκεκριμένα στελέχη χαρακτηρίστηκαν περαιτέρω με τημέθοδο MLST και spa. Στη μελέτη συμπεριελήφθησαν 925 ασθενείς (51% άνδρες, μέση ηλικία 62.8 έτη) εκ των οποίων οι 51 (5.51%) ήταν αποικισμένοι με MRSA κατάτην εισαγωγή στο νοσοκομείο. Δεκαέξι ασθενείς αποικίστηκαν με MRSA στη διάρκειατης νοσηλείας. Η προηγούμενη νοσηλεία τους τελευταίους 12 μήνες (OR: 2.52 ,95%CI: 1.30-4.88 , P: 0.006), ο σακχαρώδης διαβήτης (OR: 3.13 , 95%CI: 1.60-6.13 ,P: 0.001), η διαμονή σε οίκο ευγηρίας (OR: 26.46, 95%CI: 4.37-160.15 , P: <0.001), ηύπαρξη χρόνιων δερματικών παθήσεων (OR: 2.82 , 95%CI:1.17-6.81 , P: 0.021) και ηχρήση αντιβιοτικών εντός 6 μηνών (OR: 2.02 , 95%CI: 1.05-3.90 , P:0.036) ήτανανεξάρτητοι παράγοντες κινδύνου για αποικισμό από MRSA κατά την εισαγωγή στονοσοκομείο. Δεκαπέντε (29.41%) από τα 51 στελέχη χαρακτηρίστηκαν ως CA-MRSAμε βάση τον επιδημιολογικό ορισμό του CDC, εκ των οποίων τα 9 άνηκαν σε κλώνουςτης κοινότητας και 6 σε νοσοκομειακούς MRSA κλώνους. Οι MRSA κλώνοι τηςκοινότητας που ανιχνεύτηκαν ήταν ο ST80-IVc (n=7) και ο ST30-IVc (n=2), ενώ οινοσοκομειακοί MRSA κλώνοι ήταν ο ST239-III, ο ST5-II, ο ST105-II και ο ST22-IVc.Από τα 36 HA-MRSA στελέχη, 7 από τα 8 PVL θετικά στελέχη άνηκαν στον MRSAκλώνο της κοινότητας ST80-IVc. Τέσσερα από τα 14 στελέχη του κλώνου ST80-IVcπαρουσίαζαν αντοχή σε ≥ 3 ομάδες μη β-λακταμικών αντιβιοτικών. Πέντε από τους αποικισμένους ασθενείς (7.46%) εκδήλωσαν λοίμωξη. Οι ασθενείς αυτοί ανέπτυξανλοίμωξη από το ίδιο στέλεχος από το οποίο ήταν αποικισμένοι. Συμπερασματικά οαποικισμός με MRSA είναι συχνός σε ασθενείς με προηγούμενη νοσηλεία, χρήσηαντιβιοτικών, διαμονή σε οίκο ευγηρίας, σακχαρώδη διαβήτη και χρόνιες δερματικέςπαθήσεις. Η αλλαγή στην επιδημιολογία του MRSA που παρατηρείται τα τελευταίαχρόνια έχει ως αποτέλεσμα την ανάμειξη των MRSA κλώνων τόσο στο νοσοκομειακόπεριβάλλον όσο και στην κοινότητα. Επιπλέον, ένα σημαντικό ποσοστό τωναποικισμένων χειρουργικών ασθενών στην περιοχή μας φέρει τον Ευρωπαϊκό κλώνοST80-IVc, ο οποίος έχει την ικανότητα να αποκτά πρόσθετα γονίδια αντοχής και ναπροκαλεί νοσοκομειακές λοιμώξεις

Transmission Dynamics of Carbapenemase-Producing Klebsiella Pneumoniae and Anticipated Impact of Infection Control Strategies in a Surgical Unit

<div><h3>Background</h3><p>Carbapenemase-producing <em>Klebsiella pneumoniae</em> (CPKP) has been established as important nosocomial pathogen in many geographic regions. Transmission from patient to patient via the hands of healthcare workers is the main route of spread in the acute-care setting.</p> <h3>Methodology/Principal Findings</h3><p>Epidemiological and infection control data were recorded during a prospective observational study conducted in a surgical unit of a tertiary-care hospital in Greece. Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter. The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number <em>R₀</em> (average number of secondary cases per primary case in the absence of infection control) and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings. Eighteen of 850 patients were colonized with CPKP on admission and 51 acquired CPKP during hospilazation. <em>R₀</em> reached 2 and exceeded unity for long periods of time under the observed hand hygiene compliance (21%). The minimum hand hygiene compliance level necessary to control transmission was 50%. Reduction of 60% to 90% in colonized patients on admission, through active surveillance culture, contact precautions and isolation/cohorting, in combination with 60% compliance in hand hygiene would result in rapid decline in CPKP prevalence within 8–12 weeks. Antibiotics restrictions did not have a substantial benefit when an aggressive control strategy was implemented.</p> <h3>Conclusions/Significance</h3><p>Surveillance culture on admission and isolation/cohorting of colonized patients coupled with moderate hand hygiene compliance and contact precautions may lead to rapid control of CPKP in endemic and hyperendemic healthcare settings.</p> </div

Model of indirect transmission of CPKP between patients through health-care workers (HCWs) and impact of intervention measures.

<p>A. Model of indirect transmission of CPKP between patients through health-care workers (HCWs) who act as vectors. Solid lines depict the movement to/from the four population groups and dashed lines depict the transmission between patients and HCWs B. The impact of intervention measures in the transmission process: hand washing (allows the decontamination of HCWs), staff cohorting (reduces patients mixing with contaminated HCWs), antibiotic restriction (reduces the probability of CPKP colonization per contact with contaminated HCW), screening and isolation of colonized admissions.</p

Molecular characteristics of community-associated methicillin-resistant Staphylococcus aureus colonizing surgical patients in Greece

Fifty-one of 925 patients screened for methicillin-resistant Staphylococcus aureus (MRSA) upon admission to a surgical unit were MRSA carriers; 15 were classified as community- and 36 as hospital-associated-MRSA. Fourteen of 22 isolates typed by molecular methods belonged to the European clone ST80-IVc, 3 of which exhibited resistance to ≥3 non-β-lactam antibiotics

Observed number of patients with CPKP and model fit.

<p>Observed cumulative number of CPKP colonized patients (admissions and colonizations within the unit), CPKP colorizations within the unit and CPKP colonized admissions (solid lines) along with the corresponding model fit (dashed lines).</p

Impact of infection control measures on the prevalence of CPKP colonization in an hyperendemic setting.

<p>Infection control measures start on day 0 where a high colonization prevalence of 21% was assumed. The evaluated scenarios include: <b>1</b>. Hand hygiene compliance <i>p</i> = 60%, <b>2.... </b><i>p = </i>80%, <b>3.... </b><i>p</i> = 60% and reduce colonization prevalence on admission of CPKP by 60% (through active surveillance and subsequent isolation or strict contact precautions for positive patients), <b>4.... </b><i>p</i> = 60% and reduce colonization prevalence on admission of CPKP by 90%, <b>5.... </b><i>p</i> = 80% and reduce colonization prevalence on admission of CPKP by 90%. Dashed lines (<b>- - -</b>) correspond to the above scenarios with the addition of 50% reduction in the duration of antibiotic usage during patients' stay in the unit (assuming a relative risk associated with antibiotic use equal to 3).</p

Impact of relaxing the infection control measures on the prevalence of CPKP colonization in an endemic setting.

<p>One CPKP colonized patient enters the surgical unit on day 0 and the only infection control measure applied during the first 30 days is hand hygiene compliance (<i>p</i> = 21%). Infection control measures are implemented during three months (day 30 - day 120). After day 120, only hand hygiene measures with 60% compliance are implemented. The evaluated scenarios during day 30-day 120 include: <b>1</b>. Hand hygiene compliance <i>p</i> = 60%, <b>2.... </b><i>p = </i>80%, <b>3.... </b><i>p</i> = 60% and reduce colonization prevalence on admission of CPKP by 60% (through active surveillance and subsequent isolation or strict contact precautions for positive patients), <b>4.... </b><i>p</i> = 60% and reduce colonization prevalence on admission of CPKP by 90%, <b>5.... </b><i>p</i> = 80% and reduce colonization prevalence on admission of CPKP by 90%.</p