Costs of outpatient and inpatient MRSA screening and treatment strategies for patients at elective hospital admission - a decision tree analysis

Abstract Background Nosocomial infections are among the most common complications in hospitals. A major part is caused by multidrug-resistant organisms (MDRO). MRSA is still the most prominent and frequent MDRO. The early detection of carriers of multidrug-resistant bacteria is an effective measure to reduce nosocomial infections caused by MDRO. For patients who are planning to go to the hospital, an outpatient screening for MDRO and pre-hospital decolonization is recommended. However, the effectiveness of such pre-admission MDRO management in preparation for a planned hospital stay has not yet been sufficiently scientifically examined from an economic perspective. Methods A decision tree will be used to develop scenarios for MDRO screening and treatment in the context of the outpatient and inpatient sectors using MRSA-positive patients as an example. Subsequently, the expected costs for the respective strategy are presented. Results The decision tree analysis shows that the expected costs of outpatient MRSA management are €8.24 and that of inpatient MRSA management are €672.51. Conclusion The forward displacement of the MRSA screening to the ambulatory sector and any subsequent outpatient decolonization for patients with a planned hospitalization is the most cost-effective strategy and should become a standard benefit. Excluding opportunity costs, the expected costs of inpatient MRSA management are €54.94

Occurrence of ESBL-Producing Escherichia coli in Livestock and Farm Workers in Mecklenburg-Western Pomerania, Germany.

In recent years, extended-spectrum β-lactamases (ESBL) producing bacteria have been found in livestock, mainly as asymptomatic colonizers. The zoonotic risk for people working in close contact to animal husbandry has still not been completely assessed. Therefore, we investigated the prevalence of ESBL-producing Escherichia spp. in livestock animals and workers to determine the potential risk for an animal-human cross-transmission.In Mecklenburg-Western Pomerania, northeast Germany, inguinal swabs of 73 individuals with livestock contact from 23 different farms were tested for ESBL-producing Escherichia spp. Two pooled fecal samples per farm of animal origin from 34 different farms (17 pig farms, 11 cattle farms, 6 poultry farms) as well as cloacal swabs of 10 randomly selected broilers or turkeys were taken at each poultry farm. For identification, selective chromogenic agar was used after an enrichment step. Phenotypically ESBL-producing isolates (n = 99) were tested for CTX-M, OXA, SHV and TEM using PCR, and isolates were further characterized using multilocus sequence typing (MLST). In total, 61 diverse isolates from different sources and/or different MLST/PCR results were acquired. Five farm workers (three from cattle farms and two from pig farms) harbored ESBL-producing E. coli. All human isolates harbored the CTX-M β-lactamase; TEM and OXA β-lactamases were additionally detected in two, resp. one, isolates. ESBL-producing Escherichia spp. were found in fecal samples at pig (15/17), cattle (6/11) and poultry farms (3/6). In total, 70.6% (24/36) of the tested farms were ESBL positive. Furthermore, 9 out of 60 cloacal swabs turned out to be ESBL positive. All isolated ESBL-producing bacteria from animal sources were E. coli, except for one E. hermanii isolate. CTX-M was the most prevalent β-lactamase at cattle and pig farms, while SHV predominated in poultry. One human isolate shared an identical MLST sequence type (ST) 3891 and CTX-M allele to the isolate found in the cattle fecal sample from the same farm, indicating a zoonotic transfer. Two other pairs of human-pig and human-cattle E. coli isolates encoded the same ESBL genes but did not share the same MLST ST, which may indicate horizontal resistance gene transfer. In summary, the study shows the high prevalence of ESBL-producing E.coli in livestock in Mecklenburg- Western Pomerania and provides the risk of transfer between livestock and farm workers

Susceptibility of livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) to chlorhexidine digluconate, octenidine dihydrochloride, polyhexanide, PVP-iodine and triclosan in comparison to hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA): a standardized comparison

Background Recent publications have raised concerns of reduced susceptibilities of clinical bacterial isolates towards biocides. This study presents a comparative investigation of the susceptibility of livestock-associated Methicillin-resistant Staphylococcus aureus (LA-MRSA), hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA) to the commonly used antiseptics chlorhexidine (CHX), octenidine (OCT), polyhexanide (PHMB), PVP-iodine (PVP-I) and triclosan (TCX) based on internationally accepted standards. Methods In total, 28 (18 LA-, 5 HA- and 5 CA) genetically characterized MRSA strains representing a broad spectrum of hosts, clonal complexes and spa-types, as well as the reference methicillin-sensitive Staphylococcus aureus (MSSA) strain ATCC 6538, were selected. Minimal inhibitory concentration (MIC) and minimal microbicidal concentration (MBC) were determined in accordance with DIN 58940–7, 58940–8 and DIN EN ISO 20776-1. The microbicidal efficacy was determined in accordance with DIN EN 1040. Results Results from the MIC/MBC and quantitative suspension tests revealed differences between antiseptic substances but not between epidemiological groups of MRSA strains. OCT and PHMB were the most active substances with a minimal MIC of 1 mg/L, followed by CHX (2 mg/L), TCX (32 mg/L) and finally PVP-I (1024 mg/L). The MSSA reference strain showed a tendency to a higher susceptibility compared to the MRSA strains. Conclusions This investigation of the susceptibility of a range of LA-, HA- and CA-MRSA strains using standardized conditions gave no indication that LA-MRSA strains are less susceptible to commonly used antiseptics compared to HA- and CA-MRSA strains.Peer Reviewe

Comparison farm workers working in farms with an ESBL-positive fecal sample (n = 55)^* carrying ESBL-producing bacteria with non-carriers.

<p>* only people working in cattle farms with an ESBL-positive result were included. No significant differences could be detected.</p><p>Comparison farm workers working in farms with an ESBL-positive fecal sample (n = 55)^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0143326#t002fn001" target="_blank">*</a>} carrying ESBL-producing bacteria with non-carriers.</p

Distribution of ESBL genes in samples of human, pig, cattle and chicken origin.

<p>The figure shows the distribution of the ESBL genes CTX-M, OXA, SHV and TEM of <i>Escherichia</i> spp. isolates from humans (inguinal swabs), pig and cattle (fecal samples) and broiler (boot swabs). CTX-M ESBL dominated in pigs with 32 isolates; 8 were found in cattle, 5 in humans and 1 in poultry. OXA enzymes were rare, but most frequently isolated from cattle (n = 2). SHV were also rare and dominated in poultry (n = 2). TEM were most frequently found in isolates of pig origin (n = 11).</p

Overview of the ESBL-PCR and MLST-results of the human-livestock isolates.

<p>* due to partial <i>bla</i> sequencing, closely-related alleles could not be discriminated as the covered region was identical in all alleles. Therefore, all possible alleles were given here. In case of sequencing failure, the alleles were rated as “non-typeable”.</p><p>Overview of the ESBL-PCR and MLST-results of the human-livestock isolates.</p

Minimum spanning trees based on MLST allelic profiles portraying the clonal relationship of ESBL-producing E. coli.

<p>Each circle represents a given allelic profile (combination of the seven MLST loci) and is named according to the MLST sequence type. The numbers on the connecting lines illustrate the number of differing alleles. If applicable, the clonal complexes (CC) are shaded in grey and named. The correlations between the MLST-based phylogeny and (1A) ESBL genotype represented by the differently colored circles and (1B) origin (animal or human) of the samples are displayed.</p

Extensively drug-resistant Klebsiella pneumoniae ST307 outbreak, north-eastern Germany, June to October 2019

From June to October 2019, 17 patients (six infected, 11 colonised) with an extensively drug-resistant (XDR) Klebsiella pneumoniae strain were notified from four Western Pomerania medical facilities. The XDR K. pneumoniae produced carbapenemases NDM-1 and OXA-48, and was only susceptible to chloramphenicol, tigecycline and cefiderocol. Synergistic activity was observed for the combination of aztreonam plus ceftazidime-avibactam. Genomic analyses showed all isolates belonged to K. pneumoniae sequence type 307. Control measures and further investigations are ongoing.Peer Reviewe

Wnt/β-catenin signaling regulates VE-cadherin-mediated anastomosis of brain capillaries by counteracting S1pr1 signaling.

Canonical Wnt signaling is crucial for vascularization of the central nervous system and blood-brain barrier (BBB) formation. BBB formation and modulation are not only important for development, but also relevant for vascular and neurodegenerative diseases. However, there is little understanding of how Wnt signaling contributes to brain angiogenesis and BBB formation. Here we show, using high resolution in vivo imaging and temporal and spatial manipulation of Wnt signaling, different requirements for Wnt signaling during brain angiogenesis and BBB formation. In the absence of Wnt signaling, premature Sphingosine-1-phosphate receptor (S1pr) signaling reduces VE-cadherin and Esama at cell-cell junctions. We suggest that Wnt signaling suppresses S1pr signaling during angiogenesis to enable the dynamic junction formation during anastomosis, whereas later S1pr signaling regulates BBB maturation and VE-cadherin stabilization. Our data provides a link between brain angiogenesis and BBB formation and identifies Wnt signaling as coordinator of the timing and as regulator of anastomosis.SCOPUS: ar.jinfo:eu-repo/semantics/publishe