Against the onslaught of endemic KPC, the war is being lost on the Irish Front.

In the context of the excellent report of successful control of an outbreak of carbapenemase-producing Klebsiella pneumoniae in an Italian neonatal intensive care unit published in this journal (1), we wish to report the consequences of the first outbreak of KPC-producing Kliebsiella in Ireland and how, despite identification of operational factors associated with the incidence and best efforts towards rectifying those, our 410-bed hospital in the West of Ireland is failing to control endemic KPCs. Globally, there is recognition of the significant morbidity and mortality implications associated with emergence of carbapenemase-producing bacteria (2). The resulting vigilance has resulted in enhanced reporting of outbreaks, many being the first of their kind in specific countries (3), and descriptions of molecular studies to determine incidence and transfer of the carbapenemase-encoding blaKPC-harboring IncFIA plasmid between clonal variants (4). With indicative rates of carriage being circa 20%, infection control specialists are reacting with novel techniques for microbiological detection, strategies for prevention of nosocomial transmission, and clinical microbiologists are facing therapeutic challenges related to limited, relatively unproven antimicrobial treatment options

Limerick: forever associated with five lines of rhyme or infamous for irrepressible carbapenemase-producing enterobacteriaceae for all time?

Letter to Edito

Colonisation with extended-spectrum beta-lactamase (ESBL) not detected in a prevalence study.

Background The Mid-West of Ireland has higher than average national rates of invasive extended-spectrum beta-lactamase (ESBL) bloodstream infections and carbapenemase-producing Enterobacteriaceae (CPE), with increasing numbers of ESBL isolates detected in community-dwelling patients. Aims To conduct a point prevalence study in a convenience sample of the Mid-West population with the aim of determining the extent of ESBL colonisation Methods Utilising anonymised community stool samples that had completed routine analysis, we conducted a point prevalence study over a four-week period on all samples that met defined inclusion and exclusion criteria. Limited epidemiological data was recorded: (1) age of patient, (2) gender, (3) sender location. From these stool specimens, rectal swabs were inoculated (eSwab™ 480CE, Copan, Italy), which were subsequently cultured on selective chromogenic agar (Colorex™ ESBL). Culture plates were incubated aerobically at 37˚C for 24 hours. Results Of 195 samples processed, 58% (n=112) were from females. The median patient age was 62.4 years (range 20-94 years). 186 samples (95%) originated from general practitioner clinics. During the study period, only nine eligible stool samples were received from LTCF (6 public). From 195 Colorex™ ESBL chromogenic agar plates cultured, no ESBL-producing organisms were detected. Conclusions This community point prevalence study did not identify ESBL-colonisation despite high numbers of patients with invasive ESBL bloodstream infections presenting for admission in our institution. We believe this may be because of our small sample size. Data regarding antimicrobial exposure and other risk factors for ESBL-colonisation was also not available. We remain vigilant for ESBL-producing organisms

A case of fatal daptomycin-resistant, vancomycinresistantenterococcal infective endocarditis in end-stage kidney disease

Introduction: Ireland currently has the highest reported rate in Europe of vancomycin-resistant Enterococcus (VRE) isolated from the bloodstream, but data regarding the prevalence of VRE endocarditis remain scarce. Treatment options for Enterococcus-mediated endocarditis are limited, and therefore daptomycin is commonly used off licence in this setting. Case presentation: A 60-year-old male with end-stage kidney disease (ESKD) presented with VRE bacteraemia secondary to a gangrenous right foot colonized with vancomycin-resistant Enterococcus faecium. Aortic valve endocarditis was confirmed using transoesophageal echocardiography. Treatment was commenced with linezolid and subsequently modified to combination therapy with daptomycin and rifampicin. High-dose daptomycin therapy was employed unsuccessfully and, after 20 days of therapy, daptomycin resistance emerged, which proved fatal. Conclusion: The case was ethically challenging and involved a refusal of amputation and, ultimately, any form of treatment by the patient. In summary, however, daptomycin-resistant VRE bacteraemia complicated by recalcitrant daptomycin-resistant VRE endocarditis proved fatal for this patient. Further evaluation of the efficacy and safety of high-dose daptomycin for the treatment of VRE infective endocarditis is needed

An optimised work-flow to reduce time-to-detection of carbapenemase-producing Enterobacteriaceae (CPE) using direct testing from rectal swabs

Rapid detection of patients with carbapenem-producing Enterobacteriaceae (CPE) is essential for the prevention of nosocomial cross-transmission, allocation of isolation facilities and to protect patient safety. Here, we aimed to design a new laboratory work-flow, utilising existing laboratory resources, in order to reduce time-to-diagnosis of CPE. A review of the current CPE testing processes and of the literature was performed to identify a real-time commercial polymerase chain reaction (PCR) assay that could facilitate batch testing of CPE clinical specimens, with adequate CPE gene coverage. Stool specimens (210) were collected; CPE-positive inpatients (n=10) and anonymised community stool specimens (n=200). Rectal swabs (eSwab™) were inoculated from collected stool specimens and a manual DNA extraction method (QIAamp® DNA Stool Mini Kit) was employed. Extracted DNA was then processed on the Check-Direct CPE® assay. The three step process of making the eSwab™, extracting DNA manually and running the Check-Direct CPE® assay, took <5 minutes, 1 hour 30 minutes and 1 hour 50 minutes, respectively. It was time efficient with a result available in under 4 hours, comparing favourably with the existing method of CPE screening; average time-to-diagnosis of 48/72 hours. Utilising this CPE work-flow would allow a ‘same-day’ result. Antimicrobial susceptibility testing results, as is current practice, would remain a ‘next-day’ result. In conclusion, the Check-Direct CPE® assay was easily integrated into a local laboratory work-flow and could facilitate a large volume of CPE screening specimens in a single batch, making it cost-effective and convenient for daily CPE testing

Assessment of the FilmArray® multiplex PCR system and associated meningitis/encephalitis panel in the diagnostic service of a tertiary hospital

Rapid and accurate diagnosis of meningitis/encephalitis (M/E) is essential for successful patient outcomes. The FilmArray® meningitis/encephalitis Panel (MEP) is a multiplexed PCR test for simultaneous, rapid detection of pathogens directly from cerebrospinal fluid (CSF) samples. 94 prospectively collected CSF specimens from patients with clinical suspicion of infective M/E underwent testing for 14 pathogens simultaneously, including Escherichia coli, Haemophilus influenzae, Neisseria meningitidis, and Varicella zoster. MEP demonstrated 95% agreement with current PCR methods, resulting in 16 diagnosed cases of M/E. Typically, the FilmArray® MEP results were delivered within approximately one hour, contrasting with current practices taking up to 5.6 days. Given the significant morbidity and mortality associated with delayed diagnosis of central nervous system infections, the FilmArray® MEP is a useful addition to the diagnostic capabilities of a clinical microbiology department

Panton-Valentine leucocidin toxin-positive staphylococcus aureus-mediated neonatal mastitis.

no abstract availabl

Combined education and skin antisepsis intervention for persistently high blood-culture contamination rates in neonatal intensive care

Contaminated blood cultures represent challenges regarding diagnosis, duration of hospitalization, antimicrobial use, pharmacy and laboratory costs. Facing problematic neonatal blood culture contamination (3.8%), we instigated a successful intervention combining skin antisepsis using sterile applicators with 2% chlorhexidine gluconate in 70% isopropanol prior to phlebotomy (replacing 70% isopropanol) and staff education. In the six months prior to intervention, 364 neonatal peripheral blood samples were collected. Fourteen (3.8%) were contaminated. In the post-intervention six months, 314 samples were collected. Three (0.96%) were contaminated, representing significant improvement (Fisher’s exact test: P= 0.0259). No dermatological sequelae were observed. The improvement has been sustained

A case of Panton–Valentine leucocidin toxin-positive staphylococcus aureus-mediated neonatal mastitis

Introduction: Neonatal mastitis is an inflammatory condition of the breast frequently associated with Staphylococcus aureus. While Panton–Valentine leucocidin (PVL), a B-pore-forming cytotoxin, is commonly associated with enhanced virulence in community-acquired methicillinresistant S. aureus isolates, this is the first report to our knowledge of neonatal mastitis caused by PVL-positive S. aureus. Case presentation: A 20-day-old full-term female neonate presented with bilateral mastitis, complicated by bilateral abscess formation. PVL toxin-positive S. aureus was cultured from aspirates of both breasts. All family members, none of whom presented with symptoms of infection, and, specifically, maternal vaginal samples proved negative for PVL-positive S. aureus. Successful resolution involved surgical drainage and clindamycin therapy. Conclusion: While PVL toxin-positive S. aureus has previously been implicated in bovine and ovine mastitis, there may now be a need for vigilance with respect to human incidence. Due to PVL-mediated tissue necrosis, breast abscess formation and poor response to conventional antimicrobial therapy should, perhaps, be a cause for suspicion of PVL-bearing S. aureus and expediting of appropriate therapy to avoid potential for long-term consequences such as abnormal breast development

Clustered multidrug-resistant Bordetella petrii in adult cystic fibrosis patients in Ireland: case report and review of antimicrobial therapies

Introduction: Bordetella petrii is an emerging pathogen. Whilst association with cystic fibrosis (CF) has been described previously, this is the first report to our knowledge of multidrug-resistant B. petrii incidence in an Irish CF patient population. Case presentation: Using a case series of four adult CF patients with varying baselines of health, one of whom was asymptomatic, this report attempts correlation of B. petrii colonization, by one common strain, with incidence of acute exacerbation of symptoms. As definitive guidelines for antimicrobial sensitivity/resistance do not exist for B. petrii, we completed a systematic review of available literature to collate evidence of antimicrobial efficacy against B. petrii. Comparison with the isolates in this study indicated B. petrii sensitivity to piperacillin/ tazobactam and minocycline but resistance to antimicrobials in the macrolide, other b-lactam and fluoroquinolone groups. Conclusion: To our knowledge, this is the first report of multiple CF patients sharing a strain of B. petrii. Furthermore, B. petrii may be under-identified in CF patients and should be considered when evaluating exacerbation of CF symptoms