The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature

Abstract

Background Despite the adoption of strict infection prevention and control measures, many hospitals have reported outbreaks of multidrug-resistant organisms (MDRO) during the Coronavirus 2019 (COVID-19) pandemic. Following an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in our institution, we sought to systematically analyse characteristics of MDRO outbreaks in times of COVID-19, focussing on contributing factors and specific challenges in controlling these outbreaks. Methods We describe results of our own CRAB outbreak investigation and performed a systematic literature review for MDRO (including Candida auris) outbreaks which occurred during the COVID-19 pandemic (between December 2019 and March 2021). Search terms were related to pathogens/resistance mechanisms AND COVID-19. We summarized outbreak characteristics in a narrative synthesis and contrasted contributing factors with implemented control measures. Results The CRAB outbreak occurred in our intensive care units between September and December 2020 and comprised 10 patients (thereof seven with COVID-19) within two distinct genetic clusters (both ST2 carrying OXA-23). Both clusters presumably originated from COVID-19 patients transferred from the Balkans. Including our outbreak, we identified 17 reports, mostly caused by Candida auris (n = 6) or CRAB (n = 5), with an overall patient mortality of 35% (68/193). All outbreaks involved intensive care settings. Non-adherence to personal protective equipment (PPE) or hand hygiene (n = 11), PPE shortage (n = 8) and high antibiotic use (n = 8) were most commonly reported as contributing factors, followed by environmental contamination (n = 7), prolonged critical illness (n = 7) and lack of trained HCW (n = 7). Implemented measures mainly focussed on PPE/hand hygiene audits (n = 9), environmental cleaning/disinfection (n = 9) and enhanced patient screening (n = 8). Comparing potentially modifiable risk factors and control measures, we found the largest discrepancies in the areas of PPE shortage (risk factor in 8 studies, addressed in 2 studies) and patient overcrowding (risk factor in 5 studies, addressed in 0 studies). Conclusions Reported MDRO outbreaks during the COVID-19 pandemic were most often caused by CRAB (including our outbreak) and C. auris. Inadequate PPE/hand hygiene adherence, PPE shortage, and high antibiotic use were the most commonly reported potentially modifiable factors contributing to the outbreaks. These findings should be considered for the prevention of MDRO outbreaks during future COVID-19 waves.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital

“…Our study also found that 8.6% of hospital-acquired BSI was caused by non-albicans Candida spp . There is limited information of fungal infections, particularly of non-albicans Candida infections, as the cause of BSI in LMICs [ 44 – 47 ] The relatively high proportion of fungemia in our data, compared with 1.1% in Thailand [ 46 ], could be due the complex, immunocompromised patient populations, with common invasive procedures and high antibiotic use, all of which are risk factors of invasive candidiasis [ 31 , 48 ]. Available data worldwide suggest increasing incidence of fungemia caused by non-albicans Candida species [ 44 , 49 , 50 ] together with increasing resistance.…”

“…Nonetheless, studies from China [ 25 ], India [ 22 ], Italy [ 26 ], Taiwan [ 21 ], reported an increase in the proportion or incidence rates of AMR infections in COVID-19 patients. Multiple possible reasons for an increase include the high antibiotic use, predominance of severe COVID-19 patients in intensive care unit (ICU) with multiple predispositions towards AMR infections and protracted hospital stay, overcrowding of patients, and limited guideline adherence [ 27 – 31 ]. Therefore, appropriate antimicrobial prescribing, accurate diagnosis and appropriate infection prevention control are crucial for both COVID-19 and non-COVID-19 patients.…”

Successful control of Candida auris transmission in a German COVID‐19 intensive care unit

“…auris . 10 , 23 , 27 , 28 , 29 This requires an increased awareness of the risk of C . auris in patients coming from regions with an endemic occurrence.…”

Bioactivity and Chemical Profile of Rubus idaeus L. Leaves Steam-Distillation Extract

“…Regarding the latter, K. marina is a pathogen-emerging bacterium [79,80] which can contribute to the formation of biofilms in different stages of the food chain, increasing the chances that more pathogenic bacteria, such as Listeria monocytogenes, can survive the sanitation processes or carry out cross-contamination [81]. A. Bohemicus, which belongs to the genus Acinetobacter, is instead widely studied for its strong ability to generate multi-pharmacological resistance and the horizontal transmission of resistance-associated genes [82]. As reported by several authors, this bacterium can grow in the environment (soil and water), and its presence in the food chain can occur [83,84].…”