Significance and Impact of the Study: MALDI-TOF mass spectrometry is increasingly present in microbiology laboratories due to its increasing use for bacterial identification. This study describes a method for detection of carbapenemase activity using MALDI-TOF, which is similar to the reference method: the detection of imipenem hydrolysis using UV spectrometry. AbstractWe have evaluated a matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) method for the identification of carbapenemases and for distinguishing metallo-b-lactamases (MBLs). A total of 49 noncarbapenemase-producing and 14 carbapenemase-producing Enterobacteriaceae and Pseudomonas aeruginosa clinical strains, previously characterized by PCR, were included in the study. With MALDI-TOF MS, the presence of carbapenemases was confirmed by the detection of ertapenem hydrolysis (lost of molecular peaks: 476Á5 Da, 498Á5 Da, 520Á5 Da and presence of degradation products) in the mixture of the bacteria with the antibiotic, and classification was achieved by selective inhibition of carbapenemase activity (the ertapenem molecular peak was maintained) with ethylenediaminetetraacetic acid (EDTA). We obtained a good concordance among the results of PCR and MALDI-TOF MS. This method appears to be simple, fast and reliable for distinguishing in few hours different classes of carbapenemases, which can be very useful for epidemiological studies or to establish a specific antimicrobial therapy.

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Objectives: Inappropriate antimicrobial use favours the spread of resistance, and multidrug-resistant microorganisms (MDR) are currently of major concern. Antimicrobial stewardship programmes (ASPs) are essential for improving antibiotic use in hospitals. However, their impact on entire healthcare systems has not been thoroughly assessed. Our objective was to provide the results of an institutionally supported ASP involving 31 public hospitals in Andalusia, Spain. Methods: We designed an ecologic time-series study from 1 January 2014 to 31 December 2017. Quarterly, data on indicators were collected prospectively, and feedback reports were provided. PIRASOA is an ongoing clinically based quality-improvement programme whose key intervention is the educational interview, regular peer-to-peer interventions between advisors and prescribers to reinforce the appropriate use of antibiotics. Seventy-two indicators were monitored to measure prescribing quality (inappropriate treatments), antimicrobial consumption (defined daily doses per 1000 occupied bed-days), incidence density of MDR per 1000 occupied bed-days and crude mortality rate associated with bloodstream infections. We used Joinpoint regression software to analyse the trends. Results: The quality of antimicrobial prescribing improved markedly, and the inappropriate treatment rate was significantly lower, with quarterly percentage change (QPC) ¼ À3.0%, p < 0.001. Total antimicrobial consumption decreased (QPC ¼ À0.9%, p < 0.001), specifically carbapenems, amoxicillin/clavulanic acid, quinolones and antifungal agents, whereas antipseudomonal cephalosporin use increased.

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Mucormycosis is an uncommon opportunistic fungal infection caused by Zygomycetes. It usually affects immunocompromised, diabetic and trauma patients with infected wounds. We report a case of disseminated infection secondary to facial cutaneous mucormycosis caused by Saksenaea vasiformis in a diabetic patient who had a farming accident causing him severe head injury. The patient was treated with a combination of surgical debridement and antifungal therapy with liposomal amphotericin B, but he had a slow and fatal outcome. In cases of tissue necrosis following trauma involving wound contact with soil (i.e., potential fungal contamination), testing for the presence of Zygomycetes fungi such as S. vasiformis in both immunocompetent and immunocompromised patients is crucial. The reason is that this infection usually has a rapid progression and may be fatal if appropriate treatment is not administered.

Background Carbapenem-resistant Gram-negative bacilli (CR-GNB) are among the most threatening microorganisms worldwide and carbapenem use facilitates their spread. Antimicrobial stewardship programmes (ASPs) can help to optimize the use of antibiotics. This study evaluates the impact of a multifaceted educational ASP on carbapenem use and on the epidemiology of CR-GNB. Methods We conducted a quasi-experimental, time-series study in seven hospitals, from January 2014 to September 2018. The key intervention was composed of educational interviews promoting the appropriate use of carbapenems. The primary endpoints were carbapenem consumption and incidence density (ID) of CR-GNB. All non-duplicated CR-GNB clinical isolates were tested using phenotypic assays and PCR for the presence of carbapenemases. Joinpoint regression and interrupted time-series analyses were used to determine trends. Results A decrease in carbapenem consumption throughout the study period [average quarterly percentage change (AQPC) −1.5%, P &lt; 0.001] and a −8.170 (−16.064 to −0.277) level change following the intervention were observed. The ID of CR-Acinetobacter baumannii decreased (AQPC −3.5%, P = 0.02) and the overall ID of CR-GNB remained stable (AQPC −0.4%, P = 0.52). CR-GNB, CR-Pseudomonas aeruginosa and CR-A. baumannii IDs per hospital correlated with the local consumption of carbapenems. The most prevalent carbapenem resistance mechanisms were OXA-23 for CR-A. baumannii (76.1%), OXA-48 for CR-Klebsiella pneumoniae (66%) and no carbapenemases for CR-P. aeruginosa (91.7%). The epidemiology of carbapenemases was heterogeneous throughout the study, especially for carbapenemase-producing Enterobacteriaceae. Conclusions In conclusion, a multifaceted, educational interview-based ASP targeting carbapenem prescribing reduced carbapenem use and the ID of CR-A. baumannii.

Background Antimicrobial Stewardship Programmes (ASPs) and Healthcare-associated Infections (HAIs) Programmes are recommended by scientific societies as a key intervention to fight against antimicrobial resistance (AMR), but their implementation and sustainability are not easy to achieve. Spain is among the European countries with the highest antimicrobial consumption, as well as high AMR rates; despite this fact, development of ASPs is scarce. In this scenario, we designed and implemented a long-term comprehensive Institutional Programme for the Prevention and Control of Healthcare-associated Infections and Appropriate Use of Antimicrobials (PIRASOA) in both inpatient and outpatient care covering the whole Public Healthcare System of Andalusia, which is the most populated autonomous region in Spain with 8.4 million inhabitants. Methods/design This protocol describes the design, structure, organisation and indicators of the PIRASOA programme, as well as the methodology for its implementation development, data collection, assessment, feedback and continuity over time. This education-based multifaceted programme with institutional support is divided into two sub-programmes integrated into daily clinical practice: the HAIs sub-programme, aimed at hospitals, and the ASP sub-programme, applied to both hospitals and primary care. Conclusions The PIRASOA programme is the first institutional comprehensive education-based programme integrated into daily clinical practice to prevent and control HAIs and to optimise the use of antimicrobials implemented in the entire public healthcare system of an autonomous region in Spain, being among the first integral regional programmes in Europe. The assessment of antimicrobial consumption, clinical and microbiological indicators and reports are performed on a quarterly basis and are available for assessment and feedback in near real-time with only a three-month delay. The programme started on 1 January 2014, has been adequately implemented in all public centres of Andalusia and it is committed to be integrated into daily clinical practice. Data collection is ongoing. Long-term results will be analysed and published from 2018 onwards.