Identification of polysaccharide capsules among extensively drug-resistant genitourinary Haemophilus parainfluenzae isolates

The human commensal Haemophilus parainfluenzae is emerging as an opportunistic multidrug-resistant pathogen. The objectives of this work were to characterise a new capsular operon of extensively drug-resistant (XDR) H. parainfluenzae clinical isolates and study their resistance mechanisms using whole-genome sequencing. All strains were resistant to: ß-lactams, via amino acid changes in PBP3 (S385T, I442F, V511A, N526K and V562I); quinolones, by alterations in GyrA (S84F and D88Y) and ParC (S84F and S138T); chloramphenicol, through the presence of catS; macrolides, via the presence of mel and mef(E)-carrying MEGA element; and tetracycline, through the presence of tet(M) and/or tet(B). Phylogenetic analysis revealed high genomic diversity when compared to the H. parainfluenzae genomes available on the NCBI, the isolates from this study being closely related to the Swiss XDR AE-2096513. A full capsular operon showing homology to that of H. influenzae was identified, in accordance with the observation of a capsular structure by TEM. This study describes for the first time a capsular operon in H. parainfluenzae, a major determinant of pathogenicity that may contribute to increased virulence in XDR clinical isolates. Moreover, phylogenetic analysis suggests the possible spread of an XDR-encapsulated strain in Europe

Genome-wide analysis of urogenital and respiratory multidrug-resistant Haemophilus parainfluenzae

Objectives: To characterize the mechanisms of antimicrobial resistance and the prevalence of the polysaccharide capsule among urogenital and respiratory Haemophilus parainfluenzae isolates. Methods: Antimicrobial susceptibility was tested by microdilution. Fifty-five MDR strains were subjected to WGS and were phylogenetically compared with all the available H. parainfluenzae genomes from the NCBI database. The identification of the capsular bexA gene was performed by PCR in 266 non-MDR strains. Results: In 31 of the 42 ampicillin-resistant strains, blaTEM-1 located within Tn3 was identified. β-Lactamase-negative cefuroxime-resistant strains (n=12) presented PBP3 substitutions. The catS gene (n=14), the tet(M)-MEGA element (n=18) and FolA substitutions (I95L and F154V/S) (n=41) were associated with resistance to chloramphenicol, tetracycline plus macrolides, and co-trimoxazole, respectively. Thirty-seven isolates had a Tn10 harbouring tet(B)/(C)/(D)/(R) genes with (n=15) or without (n=22) catA2. Putative transposons (Tn7076-Tn7079), including aminoglycoside and co-trimoxazole resistance genes, were identified in 10 strains (18.2%). These transposons were integrated into three new integrative and conjugative elements (ICEs), which also included the resistance-associated transposons Tn3 and Tn10. The capsular operon was found only in the urogenital isolates (18/154, 11.7%), but no phylogenetic clustering was observed. The capsular operons identified were similar to those of Haemophilus influenzae serotype c and Haemophilus sputorum type 2. Conclusions: The identification of ICEs with up to three resistance-associated transposons suggests that these transferable elements play an important role in the acquisition of multidrug resistance in H. parainfluenzae. Moreover, the presence of polysaccharide capsules in some of these urogenital isolates is a cause for concern.This study was funded by the Fundación Española del Pulmón SEPAR (418/2017); the Instituto de Salud Carlos III through the Projects from the Fondo de Investigaciones Sanitarias (PI16/00977); CIBER de Enfermedades Respiratorias (CIBERES—CB06/06/0037; CB06/06/1102), co-funded by the European Regional Development Fund/European Social Fund (ERDF/ESF, ‘Investing in your future’) and CERCA Programme/Generalitat de Catalunya for institutional support; and the RTI2018-096369-B-100 grant. Bioinformatic analysis was supported by an Amazon Web Services (AWS) research grant to S.M.A.C. was supported by an FPU grant (Formación de Profesorado Universitario, FPU16/02202) from the Ministerio de Educación and S.M. was supported by a ‘Miguel Servet’ contract (CP19/00096) from the Instituto de Salud Carlos III

Assessment of trimethoprim-sulfamethoxazole susceptibility testing methods for fastidious Haemophilus spp.

Objectives: To compare the determinants of trimethoprim-sulfamethoxazole resistance with established susceptibility values for fastidious Haemophilus spp., to provide recommendations for optimal trimethoprim-sulfamethoxazole measurement. Methods: We collected 50 strains each of Haemophilus influenzae and Haemophilus parainfluenzae at Bellvitge University Hospital. Trimethoprim-sulfamethoxazole susceptibility was tested by microdilution, E-test and disc diffusion using both Mueller-Hinton fastidious (MH-F) medium and Haemophilus test medium (HTM) following EUCAST and CLSI criteria, respectively. Mutations in folA, folP and additional determinants of resistance were identified in whole-genome-sequenced isolates. Results: Strains presented generally higher rates of trimethoprim-sulfamethoxazole resistance when grown on HTM than on MH-F, independent of the methodology used (average MIC 2.6-fold higher in H. influenzae and 1.2-fold higher in H. parainfluenzae). The main resistance-related determinants were as follows: I95L and F154S/V in folA; 3- and 15-bp insertions and substitutions in folP; acquisition of sul genes; and FolA overproduction potentially linked to mutations in -35 and -10 promoter motifs. Of note, 2 of 19 H. influenzae strains (10.5%) and 9 of 33 H. parainfluenzae strains (27.3%) with mutations and assigned as resistant by microdilution were inaccurately considered susceptible by disc diffusion. This misinterpretation was resolved by raising the clinical resistance breakpoint of the EUCAST guidelines to ≤30 mm. Conclusions: Given the routine use of disc diffusion, a significant number of strains could potentially be miscategorized as susceptible to trimethoprim-sulfamethoxazole despite having resistance-related mutations. A simple modification to the current clinical resistance breakpoint given by the EUCAST guideline for MH-F ensures correct interpretation and correlation with the reference standard method of microdilution

National expert consensus on home-administered oncologic therapies in Spain

The diagnosis and treatment of cancer impose a significant emotional and psychological burden on patients, families, and caregivers. Patients undergo several interventions in a hospital setting, and the increasing number of patients requiring extended care and follow-up is driving the demand for additional clinical resources to address their needs. Hospital at Home (HaH) teams have introduced home-administered oncologic therapies that represent a new model of patient-centered cancer care. This approach can be integrated with traditional models and offers benefits to both patients and healthcare professionals (HCPs). Home-administered treatment programs have been successfully piloted globally, demonstrated as a preferred option for most patients and a safe alternative that could reduce costs and hospital burden. The document aims to establish the minimum recommendations for the home administration of oncologic therapies (ODAH) based on a national expert agreement. The expert panel comprised seven leading members from diverse Spanish societies and three working areas: clinical and healthcare issues, logistical and administrative issues, and economic, social, and legal issues. The recommendations outlined in this article were obtained after a comprehensive literature review and thorough discussions. This document may serve as a basis for the future development of home-administered oncologic therapy programs in Spain.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Dinamics of invasive disease caused by streptococcus pneumoniae clones related to the PCV13 serotypes not included in the PCV7

Treballs Finals de Grau de Farmàcia, Facultat de Farmàcia, Universitat de Barcelona, 2017. Tutora: M. Carme Fusté Munné[en] Streptococcus pneumoniae is an important cause of some infectious diseases that affect the population such as community-acquired pneumonia or meningitis. The diagnosis of Pneumococcal disease is based on a variety of laboratory tests that confirm the presence of the bacteria as the causal agent, starting with a Gram staining for the previous microscopic identification and the bacterial growth in a culture media. Then, it is followed by the MALDI-TOF identification once the bacterial strain is isolated; in the case of urine samples, it proceeds with an lateral flow immunoassay test. Finally the antimicrobial susceptibility profile is required to establish an appropriate treatment as well as other useful complementary properties in clinical studies. After completing this process, the monitoring of the disease is established by serotyping tests, genotyping tests, and characterization of resistance mechanisms, especially transferable by Tn916 transposon in ermB and mef genes associated with macrolide resistance and the tetM gene associated with tetracycline resistance. This whole process is needed to confirm the existence of different multidrug resistant clones emerged and spread throughout the world during the early use of antibiotics decades ago and generated by selective adaptation while naturally residing within the human upper respiratory pathways, also inhabited by other species of nosocomial streptococcus able to generate and transmit antibiotic resistances. Nowadays, the prevention of Pneumococcal disease is based on vaccination; the capsular polysaccharide is the major determinant of virulence of S. pneumoniae and it is considered the basis of the current vaccine development. The introduction of the 7-valent Pneumococcal conjugate vaccine or PCV7 has changed the epidemiology of Pneumococcal disease worldwide (2001), and later the PCV13 in 2010. However, some serotypes of PCV13 not included in the PCV7 remained as a cause of invasive disease.[sp] Streptococcus pneumoniae es un causante importante de algunas de las enfermedades infecciosas que afectan a la población como la neumonía adquirida en la comunidad o la meningitis. El diagnóstico de la enfermedad neumocócica se basa en una variedad de pruebas de laboratorio confirmatorias de la presencia de la bacteria como agente causal, empezando con una tinción de Gram para la previa identificación microscópica junto con la siembra de la muestra en medios de cultivo enriquecido, y seguido posteriormente de la identificación por MALDI-TOF una vez aislada la cepa bacteriana; en el caso de las muestras urinarias, se procede con una prueba inmunocromatográfica en tira reactiva. Finalmente se requieren las pruebas de sensibilidad a antimicrobianos para establecer un perfil adecuado de tratamiento, así como otras propiedades complementarias útiles en estudios clínicos. Una vez completado este procedimiento, se establece la vigilancia de la enfermedad mediante pruebas de identificación del serotipo, del genotipo, y la caracterización de los mecanismos de resistencia, especialmente los transferibles a través de transposones Tn916 relacionados con los genes ermB y mef asociados a resistencias a macrólidos, y al gen tetM asociado a resistencias a la tetraciclina. Todo este proceso es necesario para confirmar la existencia de diferentes clones multirresistentes que surgieron y se difundieron por todo el mundo durante los primeros usos de antibióticos décadas atrás y los cuales se generan a través de la adaptación selectiva mientras residen de forma natural dentro de las vías respiratorias superiores humanas, habitadas también por otras especies de estreptococos nosocomiales capaces de generar resistencias y transmitirlas. Actualmente, la prevención de la enfermedad neumocócica se basa en la vacunación; el polisacárido capsular es el principal determinante de virulencia de S. pneumoniae y también es la base del desarrollo de la vacuna actual. La introducción de la vacuna neumocócica conjugada heptavalente o PCV7 ha cambiado la epidemiología de las enfermedades neumocócicas en todo el mundo (2001) y posteriormente la PCV13 en el año 2010. Sin embargo, algunos serotipos de la PCV13 no incluidos en la vacuna PCV7 se mantuvieron como causa de la enfermedad invasiva

National expert consensus on home-administered oncologic therapies in Spain

The diagnosis and treatment of cancer impose a significant emotional and psychological burden on patients, families, and caregivers. Patients undergo several interventions in a hospital setting, and the increasing number of patients requiring extended care and follow-up is driving the demand for additional clinical resources to address their needs. Hospital at Home (HaH) teams have introduced home-administered oncologic therapies that represent a new model of patient-centered cancer care. This approach can be integrated with traditional models and offers benefits to both patients and healthcare professionals (HCPs). Home-administered treatment programs have been successfully piloted globally, demonstrated as a preferred option for most patients and a safe alternative that could reduce costs and hospital burden. The document aims to establish the minimum recommendations for the home administration of oncologic therapies (ODAH) based on a national expert agreement. The expert panel comprised seven leading members from diverse Spanish societies and three working areas: clinical and healthcare issues, logistical and administrative issues, and economic, social, and legal issues. The recommendations outlined in this article were obtained after a comprehensive literature review and thorough discussions. This document may serve as a basis for the future development of home-administered oncologic therapy programs in Spain

Identification of polysaccharide capsules among extensively drug-resistant genitourinary Haemophilus parainfluenzae isolates

Abstract The human commensal Haemophilus parainfluenzae is emerging as an opportunistic multidrug-resistant pathogen. The objectives of this work were to characterise a new capsular operon of extensively drug-resistant (XDR) H. parainfluenzae clinical isolates and study their resistance mechanisms using whole-genome sequencing. All strains were resistant to: ß-lactams, via amino acid changes in PBP3 (S385T, I442F, V511A, N526K and V562I); quinolones, by alterations in GyrA (S84F and D88Y) and ParC (S84F and S138T); chloramphenicol, through the presence of catS; macrolides, via the presence of mel and mef(E)-carrying MEGA element; and tetracycline, through the presence of tet(M) and/or tet(B). Phylogenetic analysis revealed high genomic diversity when compared to the H. parainfluenzae genomes available on the NCBI, the isolates from this study being closely related to the Swiss XDR AE-2096513. A full capsular operon showing homology to that of H. influenzae was identified, in accordance with the observation of a capsular structure by TEM. This study describes for the first time a capsular operon in H. parainfluenzae, a major determinant of pathogenicity that may contribute to increased virulence in XDR clinical isolates. Moreover, phylogenetic analysis suggests the possible spread of an XDR-encapsulated strain in Europe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background: Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods: This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was coprioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries. Results: In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion: This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries