Colonization with multidrug-resistant Enterobacteriaceae among infants: an observational study in southern Sri Lanka

Abstract

Background The timing of and risk factors for intestinal colonization with multidrug-resistant Enterobacteriaceae (MDRE) are still poorly understood in areas with high MDRE carriage. We determined the prevalence, timing, and risk factors associated with MDRE intestinal colonization among infants in southern Sri Lanka. Methods Women and their newborn children were enrolled within 48 h after delivery in southern Sri Lanka. Rectal swabs were collected from women and infants at enrollment and 4–6 weeks later. Enterobacteriaceae were isolated and identified as MDRE (positive for extended-spectrum β-lactamases or carbapenem resistant) using standard microbiologic procedures. We used exact methods (Fisher’s exact and Kruskal–Wallis tests) and multivariable logistic regression to identify sociodemographic and clinical features associated with MDRE intestinal colonization. Whole-genome sequencing was performed on selected MDRE isolates to identify phylogroups and antibiotic resistance-encoding genes were identified with NCBI’s AMRfinder tool. Results Overall, 199 post-partum women and 199 infants were enrolled; 148/199 (74.4%) women and 151/199 (75.9%) infants were reassessed later in the community. Twenty-four/199 (12.1%) women and 3/199 (1.5%) infants displayed intestinal colonization with MDRE at enrollment, while 26/148 (17.6%) women and 24/151 (15.9%) infants displayed intestinal colonization with MDRE at the reassessment. While there were no risk factors associated with infant colonization at enrollment, multivariable analysis indicated that risk factors for infant colonization at reassessment included mother colonized at enrollment (aOR = 3.62) or reassessment (aOR = 4.44), delivery by Cesarean section (aOR = 2.91), and low birth weight (aOR = 5.39). Of the 20 MDRE isolates from infants that were sequenced, multilocus sequence typing revealed that 6/20 (30%) were clustered on the same branch as MDRE isolates found in the respective mothers. All sequenced isolates for mothers (47) and infants (20) had at least one ESBL-producing gene. Genes encoding fosfomycin resistance were found in 33/47 (70%) of mothers’ isolates and 16/20 (80%) of infants’ isolates and genes encoding resistance to colistin were found in one (2%) mother’s isolate. Conclusions Our results suggest that a substantial proportion of infants undergo MDRE intestinal colonization within 6 weeks of birth, potentially due to postnatal rather than intranatal transmission.

Comprehensive analysis of antimicrobial resistance in the Southwest Indian Ocean: focus on WHO critical and high priority pathogens

“…These isolates included K. pneumoniae carrying bla KPC , bla OXA-48- like , and both bla NDM and bla OXA-48- like ; E. coli carrying the bla OXA-48- like gene, C. freundii carrying bla OXA-48- like and bla NDM , Providencia rettgeri and E. cloacae both carrying bla NDM ; and Klebsiella aerogenes harboring both bla NDM and bla OXA-48- like ( 32 ). In a separate study between August 2016 and January 2017, four carbapenem-resistant K. pneumoniae isolates were detected in four infants in a post-partum ward ( 33 ). Additionally, between 2018 and 2019, a nine-month descriptive cross-sectional study reported the presence of 37 CRE isolates (resistance rate: 41.1%) among patients with cancer in a hospital ( 34 ).…”

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“…The percentage of infants colonized with MDRE increased from 1.5% at birth to 15.9% by 6 weeks of age, suggesting community-acquired colonization in the postnatal period may be from maternal skin contact or breastmilk. 15 A systematic review and meta-analysis that focused on pregnant and postpartum women in Africa also found prevalence of maternal colonization around 17%. The risk factors related to colonization may be due to regional differences in antibiotic use in medical settings and farm animals, poverty levels, and contamination of drinking water.…”

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“…Due to the growing prevalence of multidrug-resistant Enterobacteriaceae, the efficacy of existing antibacterial agents decreases with time, while the discovery and approval of new antimicrobial agents lag behind the spread of AMR; therefore, efforts should be taken for timely updating of the existing guidelines to ensure the efficacy of antimicrobial treatment [ 29 , 30 , 31 ].…”