Antimicrobial Resistance & Infection Control

BackgroundHealthcare-associated infections (HAIs) are a major problem in healthcare facilities. In Cameroon, maternal and neonatal mortality remain a concern. The underlying determinants include shortcomings in the quality of care, inadequate infrastructure and inconsistent application of infection control and prevention (ICP) measures. The objective of this study was to identify risks that increase the likelihood of HAIs in the obstetrics-gynecology unit of a referral hospital of Yaounde. MethodsA descriptive cross-sectional study was conducted in the obstetrics-gynecology department of referral hospital of Yaounde from April to July 2024. Exposure data were collected using a self-administered questionnaire with a scoring grid to assess the level of implementation of the ICP framework. Samples were collected from the ward environment for identification of the bacterial flora of the care environment and antibiotic susceptibility testing. ResultsA total of 41 healthcare workers were enrolled in the study. Participants were predominantly female (78%) and aged 20 to 57 (median of 30) years. Hand hygiene knowledge of was average, with a median score of 60%. More than two-thirds of respondents (n=30; 73%) reported that they did not systematically practice hand hygiene before and after patient care. The most common reason for not practicing hand hygiene was the absence of a hand-washing site nearby healthcare post (57%). Face shields were the most reported unavailable equipment (81%). The overall score indicated that the obstetrics-gynecology department had a basic level of implementation of ICP interventions. Microbial analysis revealed that taps and trolleys were the most commonly soiled equipment, harboring bacterial flora of Staphylococcus aureus (36%) and other Staphylococcus spp. (24%). Proteus mirabilis (13%) and Klebsiella spp. (7%). The isolated bacterial strains showed varying degrees of resistance to antibiotics, including cephalosporin, methicillin and penicillin. ConclusionsSuboptimal IPC implementation was observed in this obstetrics-gynecology setting. Comprehensive interventions are needed, including: strengthened IPC adherence, national antibiotic regulation, healthcare worker education, and establishment of antimicrobial resistance surveillance programs.

BackgroundSince the emergence of SARS-CoV-2, health care workers (HCWs) have been on the front line in caring for COVID-19 patients. Better knowledge of risk factors for SARS-CoV-2 infection is crucial for the prevention of disease among this population. MethodsWe conducted a seroprevalence survey among HCWs in a French university hospital after the first wave (May-June 2020), based on a validated lateral flow immuno-assay test (LFIAT) for SARS-CoV-2. Demographic characteristics as well as data on the working characteristics of COVID-19 and non-COVID-19 wards and 23 care activities were systematically recorded. The effectiveness of protective equipment was also estimated, based on self-declaration of mask use. SARS-CoV-2 IgG status was modelled by multiple imputations approach, accounting for the performance of the test and data on serum validation ELISA immunoassay. FindingsAmong the 3,234 enrolled HCWs, the prevalence of SARS-CoV-2 IgG was 3.8%. Contact with relatives or HCWs who developed COVID-19 were risk factors for SARS-CoV-2 infection, but not contact with COVID-19 patients. In multivariate analyses, suboptimal use of protective equipment during naso-pharyngeal sampling, patient mobilisation, clinical and eye examination was associated with SARS-CoV-2 infection. In addition, patients washing and dressing and aerosol-generating procedures were risk factors for SARS-CoV-2 infection with or without self-declared appropriate use of protective equipment. InterpretationMain routes of transmission of SARS-CoV-2 IgG among HCWs were i) contact with relatives or HCWs with COVID-19, ii) close or prolonged contact with patients, iii) aerosol-generating procedures.

BackgroundKlebsiella pneumoniae complex (Kp) is a relevant neonatal pathogen colonizing preterm infants. While outbreak investigations often focus on multidrug-resistant strains, the epidemiology and genomic dynamics of wild-type Kp in nonoutbreak neonatal intensive care unit (NICU) settings remain elusive. MethodsWe conducted a 30-month (October 2021 to March 2024) cohort study with weekly active, unselective colonization surveillance of all NICU patients to identify risk factors for nosocomial Kp acquisition and drivers of transmission in a tertiary 21-bed NICU/intermediate care unit (IMC) in Germany. ResultsAmong 936 patients, 8.7% carried Kp, of which 70.4% were nosocomial. Very low birth weight (VLBW; <1500 g) was the only independent risk factor for nosocomial acquisition (adjusted odds ratio [aOR], 3.42; 95% CI, 1.29-9.32). Kp infections occurred in three Kp carriers (3.7%). Genomic analyses of at least the first isolate per patient (83 in total) revealed an oligoclonal population structure, with distinct sequence types driving temporally overlapping clusters. Ten genomic clusters (median size, four patients) were identified, with markedly higher odds in VLBW infants (aOR, 8.76; 95% CI, 2.45-34.16). Nosocomial cluster-assigned cases had higher rates and longer durations of noninvasive ventilation and peripheral venous catheter use. Cluster prevalence showed climate-associated variation, with a six-feature extreme gradient boosting (XGBoost) model identifying temperature and humidity among the strongest predictors. ConclusionsPatient- and climate-associated parameters are main drivers of nosocomial wild-type Kp acquisition and cluster occurrence. Comprehensive surveillance and risk-adapted infection prevention and control support sustainable Kp control in VLBW infants.

Background: Carbapenemase producing Enterobacterales (CPE) remain a major infection prevention and control challenge. Although care home residence is frequently perceived as a risk factor for CPE carriage, its independent association with CPE positivity remains uncertain. Objective: To investigate the relationship between care home residence on admission and CPE positivity among patients undergoing CPE screening. Methods: A retrospective matched case control study was conducted at a single NHS acute hospital in England. Adult patients with laboratory confirmed CPE positivity from screening samples between 1 November 2022 and 1 November 2025 were matched to CPE negative controls at a ratio of up to 1:4 based on ward, specimen year and age no more than 5 years older or younger. Conditional logistic regression was used to assess the association between care home residence and CPE positivity. An adjusted model included previous hospital admission within 12 months. Results: A total of 108 CPE positive cases were successfully matched to 412 controls. Care home residence was identified in 14 (13.0%) cases and 49 (11.9%) controls. In the matched conditional logistic regression model, care home residence was not associated with CPE positivity (OR 1.15, 95% CI 0.58 to 2.28; p=0.690) and remained non-significant after adjustment (aOR 1.32, 95% CI 0.66 to 2.64; p=0.439). Discussion: Care home residence was not independently associated with CPE positivity in this low-prevalence setting. Significance and impact: The findings do not support the use of care home residence alone to guide CPE screening. Further multicentre studies are required to clarify the contribution of care home residence to CPE epidemiology.

Antimicrobial resistance (AMR) is a growing global health threat that contributes to substantial neonatal mortality. Bangladesh has reported some of the highest rates of AMR among bacteria causing neonatal sepsis. To better understand routes of AMR transmission to newborns, we aimed to characterize the frequency of and risk factors for AMR colonization of mothers and newborns during hospitalization for delivery. We enrolled 177 pregnant women presenting for delivery to a tertiary care hospital in Faridpur, Bangladesh, during February-October 2020. We collected vaginal and rectal swabs from mothers on presentation and after delivery as well as rectal swabs from newborns. We also collected swabs from the hospital environment proximal to the patients. Swabs were plated on chromogenic agars selective for extended-spectrum-beta-lactamase producing organisms (ESBL) and carbapenem-resistant organisms (CRO). We performed univariable and multivariable analyses to determine factors associated with ESBL/CRO colonization. Prior to delivery, 17% of mothers had vaginal colonization and 71% had rectal colonization with ESBLs; 4% had vaginal colonization and 13% had rectal colonization with CROs. Seventy-nine percent of women underwent cesarean deliveries (C-section). Ninety-eight percent of women received prophylactic antibiotics during hospitalization. Following delivery, nearly 90% of mothers and newborns were colonized with ESBLs and over 70% with CROs. Of the 290 environmental samples, 77% were positive for ESBLs, and 69% were positive for CROs. Maternal and newborn colonization at discharge were both associated with C-section (RR for maternal 1.4; 95% CI 1.0-1.8 and newborn 1.3; 95% CI 1.1-1.7). Facility-based deliveries increase exposure to AMR organisms, likely driven by intense use of antibiotics and frequent C-sections. Greater attention should be given to the use of perinatal antibiotics, indications for C-sections, and infection prevention practices to reduce the high prevalence of colonization with antibiotic resistant bacteria.

ImportanceDue to high community transmission of the Omicron variant, healthcare workers (HCWs) have been increasingly reporting household exposures to confirmed COVID-19 cases. Quebec (Canada) provincial guidelines required to quarantine these HCWs. Facing the risk of staffing shortages, our hospital decided to allow them to work. ObjectiveTo evaluate the risk for HCWs, who were household contacts, to become positive for COVID-19 by RT-PCR and evaluate the risk of nosocomial COVID-19 transmission. DesignCohort of HCWs with a history of household exposure to a confirmed case of COVID-19. SettingCHU Sainte-Justine, a tertiary care mother and child center in Montreal (QC) Canada ParticipantsConsecutive HCWs who contacted OHS between December 20, 2021 and January 17, 2022 for a history of household exposure to COVID-19. ExposureConfirmed case of COVID-19 in the household Main outcome and measuresThe main outcome was a positive RT-PCR for SARS-CoV-2. Outbreaks and nosocomial cases were identified through daily analysis of COVID-19 cases, by sector and part of the usual Infection Prevention and Control surveillance process. ResultsOverall, 237 of 475 (50%) HCWs who declared a known household contact with a confirmed COVID-19 case remained negative. Of those who became positive, 196 (82.4%) were positive upon initial testing and were quarantined. Only 42 (15%) of 279 HCWs who were allowed to work became positive, a median of 4 days after the initial test. The absence of symptoms at initial evaluation (OR 3.8, 95% CI 2.5-5.7) and having received a third vaccine dose more than 7 days before (OR 1.88, 95% CI 1.3 - 2.8) were associated with an increased odds of remaining negative. There was no outbreak among HCWs and no nosocomial transmission to patients from a HCW that was allowed to work, while a known household contact. Conclusion and relevanceMeasures taken to protect the health care environment from COVID-19 must be cautiously balanced with the risk of staffing shortage. Allowing vaccinated asymptomatic HCWs who are known household contacts of confirmed COVID-19 cases to work is likely a safe alternative, when staff shortage is anticipated.

Antimicrobial resistance constitutes a major threat to global public health. Among emerging extensively drug-resistant bacteria (eXDR), carbapenemase-producing Enterobacteriaceae (CPE) expose hospitals to outbreaks through rapid dissemination, and to therapeutic limitations. Through a mixed epidemiological-qualitative methods study, we report the most extensive CPE carriage outbreak known to date in France, which occurred at Hopital Europeen Marseille (HEM) between January and June 2025. By the end of November 2024, the admission of an index patient returning from Senegal carrying an NDM-producing Escherichia coli led to an extensive transmission, despite adherence to national screen and isolate guidelines. More than 7,500 rectal screening tests evidenced 481 CPE carriers (including 343 NDM, 129 OXA-48-like and 9 other CPE), and 14 vancomycin-resistant Enterococcus faecium carriers. This major outbreak conducted to a phenomenal involvement of clinical, technical and administrative teams within the institution. It highlighted operational limitations in current screening, cohorting and biocleaning strategies in the context of hospital-wide outbreak. We describe the outbreak trajectory, the control measures implemented and provide a structured synthesis of lessons learned across organisational, scientific and policy domains.

BackgroundHospitalized patients are at risk for developing hospital acquired infections. Active surveillance for bacterial colonization is effective at preventing infection but is resource-intensive and limited to high-risk units and a subset of high-risk pathogens. Colonization pressure (CP) for common pathogens has been associated with hospital acquired infection and can be calculated in real-time using data in the electronic health record. We aimed to assess the impact of CP on nosocomial acquisition for a range of drug susceptible and drug resistant pathogens, across an entire hospital system. MethodsWe conducted a retrospective matched cohort study of all inpatients admitted to a large regional integrated healthcare system between May 2015 and July 2024 who stayed in one room during the 30 day observation period. Cases had target organisms detected in any clinical or surveillance culture taken between 3 and 30 days after admission into their first room. Controls were matched on demographics, length of stay, prior surgery and 14 classes of antibiotic exposure. Our outcome was nosocomial acquisition of 11 common pathogens spread across enteric, skin and environmental niches. We applied conditional logistic regression and XGBoost to model nosocomial acquisition using as covariates the Elixhauser comorbidity index and CP, defined as the time-weighted prevalence of an organism in ward co-occupants over the previous 6 months. CP was calculated for 9 organism sets, including the Enterobacterales, ESBL Enterobacterales, vancomycin susceptible and resistant Enterococcus spp, C. difficile, methicillin susceptible Staphylococcus aureus (MSSA), methicillin resistant S. aureus (MRSA) and drug susceptible and drug resistant (DR) P. aeruginosa (PsA). FindingsOur pooled cohort included 14,923 cases matched to 28,480 controls. Hospital acquisition occurred four times more frequently for drug susceptible versus drug resistant organisms. Baseline characteristics were well matched between cases and controls. The strongest positive associations were between CPC. difficile and nosocomial acquisition of C. difficile (+32.5%, 95% CI +21.9% to +44.0%), CPESBL and ESBL K. pneumoniae (+29.4%, 95% CI +11.3% to +50.6%), and CPPsA-DR with drug resistant P. aeruginosa (+28.6%, 95% CI +14.0% to +45.0%). Among the skin flora, CPMSSA was associated with a +12.1% (95% CI +9.9% to +14.4%) increase in the odds of nosocomial acquisition of MSSA, CPMRSA was associated with a +6.7% (95% CI +1.3% to +12.5%) increase in the odds of MRSA. Negative associations were observed between organisms inhabiting different niches, including CPMSSA and ESBL K. pneumoniae (-7.9%, 95% CI -15.1% to -0.2%), and CPPsA-DR and vancomycin susceptible E. faecalis (-10.0%, 95% CI -15.6% to -4.0%). InterpretationA hospitalized patients odds of nosocomially acquiring a potential pathogen is associated with its prevalence among that patients ward co-occupants, regardless of the organisms drug resistance profile. Further research is necessary to understand the role of passive surveillance of CP for preventing infection. FundingLWS was supported by the NLM (2T15LM007092-31). ZW was supported with institutional funding from the Department of Population Medicine. TRP was supported by AHRQ (K08-HS030118). SK was supported by AHRQ (grant no. K08 HS027841-01A1).

SummaryO_ST_ABSBackgroundC_ST_ABSThe COVID-19 pandemic led to major disruptions in healthcare services at the hospital and community levels. The resulting impact on antibiotic resistance (ABR) in hospitals is difficult to predict. MethodsWe exploited data from the French national surveillance system over four years (2019-2022) including 414 hospitals across 12 French regions. We evaluated changes in annual antibiotic use compared to 2019 using multiple comparison tests. We also compiled a large dataset of 692,551 incident isolates for five antibiotic-bacterium pairs. Using negative binomial regression models accounting for autocorrelation and antibiotic use, we evaluated associations between resistant isolates incidence and COVID-19 indicators (pandemic periods or intubated COVID-19 patient prevalence). We investigated how these associations varied specifically in ICUs (n=85) and across geographical regions. FindingsThe use of some antibiotics, including azithromycin, imipenem and meropenem, significantly increased between 2020 and 2022. Concomitantly, the incidence of methicillin-resistant Staphylococcus aureus (up to 37%, 95% CI: 18-53%) and ESBL-producing Escherichia coli (up to 33%, 95% CI: 16-46%) isolates significantly decreased in hospitals and ICUs during the pandemic. A transient decrease in ICUs was also observed for ESBL-producing Klebsiella pneumoniae during periods of strong anti-COVID-19 interventions in the community (24%, 95% CI: 6-38%). No significant changes for ESBL-producing Enterobacter cloacae complex were observed. Very interestingly, the incidence of carbapenem-resistant Pseudomonas aeruginosa isolates was associated with COVID-19 intubation prevalence in hospitals (p<0.001) and ICUs (p<0.001), notably in the regions most affected by the pandemic. InterpretationOur results highlight strong modifications of antibiotic use and pathogen-specific global impacts of the COVID-19 pandemic on ABR in hospitals. Even though the biological mechanisms underlying between- species differences remain unclear, these results provide important insights into the potential impacts of a viral pandemic on ABR and support the need for pandemic preparedness in healthcare facilities. FundingANR-10-LABX-62-IBEID. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed for articles in English published between Jan 1, 2020, and August 31, 2024 exploring national-scale changes in antibiotic resistance (ABR) within healthcare settings during the COVID-19 pandemic. Search terms for titles and abstracts were ("antibiotic resistance" OR "antimicrobial resistance" OR "bacterial resistance" OR "drug resistance" OR "MRSA" OR "ESBL" OR "carbapenem resistant") AND ("hospital" OR "healthcare") AND ("COVID-19" OR "SARS-CoV-2") AND ("national" OR "nationwide"). The search yielded 94 results. We identified 12 relevant studies after filtering out articles referring to viruses, parasites, or fungi, focusing on a single hospital, evaluating changes in antibiotic use only, assessing healthcare workers practices, or using qualitative approaches. All studies used either national surveillance data on antibiotic resistance or large multi-center cohorts of inpatients. Five studies showed a significant increase in MRSA, at least during the first wave of the COVID-19 pandemic, while two studies did not find changes at the national level compared to 2019. Interestingly, one study showed that the abandonment of infection prevention and control strategies that specifically target hospital-acquired MRSA infections was associated with an increase of these infections, regardless of COVID-19 admission prevalence. One study in Spain showed decreased resistance of P. aeruginosa to all tested antibiotics in 2022 compared to 2017, using point prevalence survey results. Conversely, one study focusing on US Veterans Affairs hospitals showed increased incidence and resistance of healthcare-associated carbapenem-resistant P. aeruginosa (CR-PA) infections during the pandemic. Most studies used univariate statistical approaches. Only two studies included COVID-19-related variables in their models; they found no association with MRSA or extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae. Added value of this studyHere, we provide the first evaluation of the impact of the pandemic on antibiotic consumption and resistance for five antibiotic-bacterium pairs (MRSA, CR-PA, ESBL-producing E. coli, ESBL-producing K. pneumoniae, and ESBL-producing E. cloacae complex) in hospitals, at the national and regional scales. By analyzing French surveillance data from the SPARES database including 414 hospitals that represent up to 14% of French hospitals, we evaluated annual changes in antibiotic use and quantified the impacts at the weekly level of the COVID-19 pandemic on the incidence of five of the most prevalent resistant bacteria in France. Accounting for autocorrelation and antibiotic use, factors that were not considered in previous studies, we report a significant positive association between the weekly incidence of CR-PA isolates and the prevalence of intubated COVID-19 patients in the preceding weeks. Carbapenem use and intubation being risk factors of CR-PA infections, our results suggest a direct impact of the pandemic on CR-PA epidemiology. Inversely, we show that the incidence of ESBL-producing E. coli and MRSA isolates decreased after the start of the first pandemic wave at the hospital level but also in ICUs. The fine grain analysis across 12 French administrative regions revealed regional heterogeneities, but highlighted consistent associations in the regions most affected by the COVID-19 pandemic. Implications of all the available evidencePandemics not only destabilize healthcare systems by adding pressure and changing healthcare worker behaviors, but also influence the epidemiology of other infectious diseases as shown in our study. We specifically highlight the contrasting effects of the COVID-19 pandemic on ABR in French hospitals, associated with an increase in CR-PA isolate incidence but a general decrease in ESBL-producing E. coli and MRSA. This work highlights how national-scale hospital surveillance systems such as SPARES that collect data at the weekly level are key to capture the evolving impacts of pandemics. They also allow to generate hypotheses on the potential mechanisms of action of the pandemic on ABR epidemiology, as showcased by the analysis of CR-PA isolates incidence, and thereby participate in the improvement of healthcare systems in pandemic context.

Structured abstractO_ST_ABSObjectivesC_ST_ABSWe aimed to design and produce a low-cost, ergonomic, hood-integrated Powered Air-Purifying Respirator (Bubble-PAPR) for pandemic healthcare use, offering optimal and equitable protection to all staff. We hypothesised that participants would rate Bubble-PAPR more highly than current FFP3 face mask respiratory protective equipment (RPE). DesignRapid design and evaluation cycles occurred based on the identified user needs. We conducted diary card and focus group exercises to identify relevant tasks requiring RPE. Lab-based safety standards established against British Standard BS-EN-12941 and EU2016/425. Questionnaire-based usability data from participating frontline healthcare staff before (usual RPE) and after using Bubble-PAPR. SettingOverseen by a trial safety committee, evaluation progressed sequentially through laboratory, simulated, low-risk, then high-risk clinical environments of a single tertiary NHS hospital. Participants15 staff completed diary cards and focus groups. 91 staff from a range of clinical and non-clinical roles completed the study, wearing Bubble-PAPR for a median of 45 minutes (IQR 30-80 [15-120]). Participants self-reported a range of heights (mean 1.7m [SD 0.1, range 1.5-2.0]), weights (72.4kg [16.0, 47-127]) and body mass indices (25.3 [4.7,16.7-42.9]). Outcome measuresPrimary: "How comfortable do you feel in your PPE?" (Likert scale bounded by 1 [very uncomfortable] to 7 [very comfortable]). Secondary outcomes: perceived safety, communication, anxiety, discomfort, and performance. ResultsBubble-PAPR mean comfort score was 5.64(SD 1.55) versus usual FFP3 2.96(1.44) (mean difference 2.68 (95% CI 2.23-3.14, p<0.001). There was a significant difference in favour of Bubble-PAPR across all secondary outcomes. ConclusionsBubble-PAPR achieved its primary purpose of keeping staff safe from airborne particulate material whilst improving comfort and the user experience. The design and development of Bubble-PAPR were conducted using a careful evaluation strategy addressing key regulatory and safety steps, in contrast to many devices rapidly developed and deployed during the pandemic. Trial registrationIRAS ID:288493, REC Ref:21/WA/0018. ClinicalTrials.gov (NCT04681365). Strengths and limitations of this studyO_LIWe employed user-centred design, engineering optimisation and staged feasibility testing to develop a novel Powered Air-Purifying Respirator (Bubble-PAPR) for use specifically in frontline healthcare settings. C_LIO_LIDiverse, frontline healthcare staff compared Bubble-PAPR with usual FFP3 face masks. C_LIO_LIThe design and development of Bubble-PAPR were conducted using a careful strategy addressing key regulatory and safety steps, in contrast to many devices rapidly developed and deployed during the pandemic. C_LIO_LIBubble-PAPR is an excellent example of developing a cosmopolitan network that could become a key feature of future system resilience. C_LI

BackgroundGood hand hygiene compliance amongst healthcare workers is critical for patient safety and plays a central role in preventing healthcare-associated infections. The World Health Organization (WHO) recommends a multimodal strategy to improve healthcare worker hand hygiene. We aimed to evaluate the effectiveness of this strategy in a middle-income country using a stepped-wedge cluster randomized trial. MethodsThe trial was conducted between 2013 and 2015 in 58 wards in a 1000-bed hospital in Thailand. The intervention was adapted from the WHOs Hand Hygiene Improvement Strategy and implemented by the hospitals infection control team. The primary outcome was observed hand hygiene compliance among healthcare workers in the study wards. This study was registered at ClinicalTrials.gov (NCT01933087). FindingsDuring 4,230 observation sessions, 54,073 hand hygiene opportunities were identified. Hand hygiene compliance increased from 10.0% (2,660/26,482) to 11.0% (3,048/27,591) after the intervention (odds ratio [OR] 1.12; 95% CI: 1.01-1.24). Among the five moments for hand hygiene, the greatest improvement in compliance was observed in hand hygiene before patient contact (OR 1.52; 95% CI: 1.21, 1.91). InterpretationWhile hand hygiene compliance improved slightly, the intervention failed to achieve the substantial improvements that were needed. There is a need for new strategies to ensure that all hospitals in low and middle-income countries can achieve and maintain acceptable levels of hand hygiene. FundingOak Foundation, MRC

IntroductionAccidental exposure to body fluids (AEBs) increases the risk of blood-borne infections among susceptible HCWs. While 90% of the AEB reported occur in developed nations, developing countries bear 90% of the burden of healthcare associated infections, especially those of sub-Saharan Africa. Social insecurity may contribute further to the vulnerability of HCWs. Our study sought to determine the prevalence, reporting and management of AEBs among HCWs in the security-challenged Region of South-West Cameroon. MethodsA cross-sectional study was carried out from February 2023 to April 2023, at the Buea Regional Hospital. Following informed consent, a 28-item interviewer-administered questionnaire to HCW was used. Data was entered and analyzed using R Statistics version 4.3.1. ResultsOut of the 230 HCWs that were approached, 200 were responded for a participation rate of >85%. The prevalence of AEB was high (93%). Exposures occurred while administering injections (37%), during blood sample collection (16%), delivery (11%), surgery (10.2%) and washing. The main risk factors for AEB included female gender (aOR=2.86) and those exercising in the medical (aOR=5.95), pediatrics (aOR=10.5), obstetrical (aOR=22.6), dental (aOR=26.3) units. Only 46.8% of AEBs were reported. Post-exposure management was carried out for 67.2% of the reported cases. Most HCW were unaware of the existence of an Infection Control Committee within the study setting, corroborating gaps in the observance of Standard Precautions. ConclusionsMost HCWs experienced AEBs over the last year. There is a need to sensitize and enforce the observance of universal precautions among HCW of the Buea Regional Hospital. Such measures should be extended to other health facilities in related settings.

Backgroundthe optimal treatment duration for group A streptococcal pharyngitis (GAS-P) is debated. Shorter courses appear inferior for pharyngeal GAS eradication, however the effect of this on household transmission is uncertain. In 2022 a laboratory reporting change drove reduced treatment durations for GAS-P in our region. This study sought to assess the effect of this on outcomes. Methodspositive throat swab cultures (TSC) for GAS from two years pre-change until 21 months post-change were matched to antibiotic dispensing data. Logistic models were fitted to examine associations between treatment duration and 30-day repeat antibiotic treatment, repeat GAS-positive TSC, and hospitalisation with complications; 90-day incidence of rheumatic fever; 30-day incident household GAS-P cases. Results865 patients pre-change and 1604 post-change were included. Pre-change 32.8% received [&le;]7 days treatment, versus 60.0% post-change (p<0.01). There were no significant differences across any outcome measure at a population level between periods. When the post-change period was examined specifically, no significant differences occurred for any outcome measure for patients receiving five- or seven-days of antibiotics versus ten-days. Patients receiving no antibiotics also had similar outcomes, except for significantly higher odds of 30-day household cases (aOR 2.93, 95%-CI 1.44-5.96, p<0.01). Conclusionsshorter treatment durations driven by a change in laboratory reporting resulted in no detectable change in GAS-P outcomes, except for more common household transmission in those receiving no treatment.

Background Antimicrobial stewardship (AMS) and infection prevention and control (IPC) are complementary strategies to improve patient safety and address antimicrobial resistance (AMR). In low- and middle-income countries (LMICs), they are often implemented separately, reducing effectiveness. Evidence on integrating AMS and IPC in routine hospital practice remains limited. Objective To evaluate the feasibility of an integrated AMS-IPC improvement approach and describe changes in implementation in Vietnamese hospitals. Methods We conducted a multisite quality improvement initiative in four hospitals within the national AMR surveillance network in Viet Nam (March-September 2025). We used US-CDC tools to guide the implementation, including the Global Antibiotic Stewardship Evaluation Tool (G-ASET) and the Infection Control Assessment and Response (ICAR) tool. Baseline assessments were followed by feedback, multidisciplinary action planning, and targeted capacity building. Follow-up occurred 2-5 months later. Changes were analysed descriptively using quantitative scores and qualitative synthesis, and reported following the SQUIRE 2.0 guidelines. Results All hospitals had established IPC programmes at baseline, while AMS maturity varied. G-ASET scores improved across all sites, with greater gains in hospitals starting from lower baselines. Key improvements included leadership and governance, education and training, stewardship actions, and monitoring and reporting. IPC practices aligned with AMS priorities also improved, particularly transmission-based precautions, environmental cleaning, and cross-team coordination. Infrastructure-dependent areas, such as water safety, showed limited short-term progress. Conclusions An integrated AMS-IPC approach using repeated assessment and feedback is feasible and associated with meaningful improvements. This model offers a scalable strategy for strengthening hospital responses to AMR in LMICs and informs national programmes.

BackgroundKlebsiella pneumoniae (Kpn) is an important cause of neonatal sepsis in sub-Saharan Africa. Kpn are intrinsically resistant to penicillins and frequently resistant to gentamicin and 3rd-generation cephalosporins, key agents in the treatment of neonatal sepsis. Such infections can be prevented by effective infection prevention and control (IPC), but the most effective IPC packages for resource-limited healthcare settings are incompletely defined. MethodsWe recruited a cohort of 94 neonates admitted to a Malawian neonatal unit, alongside their mothers, and utilised single colony whole genome sequencing and post-enrichment metagenomics to determine the most important transmission routes of Extended-Spectrum Beta-Lactamase producing (ESBL) Kpn. These data were analysed at the level of ST and pairwise SNP distance and combined with statistical models to infer transmission. FindingsESBL-Kpn rapidly colonised neonates; female sex, receipt of oxygen, caesarean delivery and antibiotic use increased colonisation risk. STs causing invasive infection and stool colonisation were temporally related to those found in the ward. There was greatest circulation of ESBL-Kpn between compartments that are in contact with neonatal stool (neonate stool, mothers hands, cots, and the swaddling cloths). Utilising epidemiological and SNP data, Kpn appeared to be transmitted to neonates primarily from cots, ward surfaces (sinks and oxygen delivery equipment) and from other neonates. Network analysis implicated cots, antibiotics and oxygen delivery in ESBL-Kpn transmission. InterpretationAn unsafe hospital environment is strongly implicated in neonatal invasive infection and stool colonisation with ESBL Kpn. IPC interventions should focus on containing neonatal stool, hand hygiene, cot decontamination, single use oxygen delivery and surface cleaning, particularly sinks. FundingThis work was funded by the Antimicrobial Resistance Cross-Council Initiative through grants from the Medical Research Council, a Council of UK Research and Innovation and the National Institute for Health Research (MR/R015074/1 & MR/S004793/1); and the Bill and Melinda Gates Foundation (INV-005692). Malawi-Liverpool-Wellcome Research Programme (MLW) is core-fund by Wellcome (206545/Z/17/Z). Research in contextO_ST_ABSEvidence before this studyC_ST_ABSNeonatal sepsis is a leading cause of neonatal mortality, particularly in sub-Saharan Africa. Klebsiella pneumoniae (Kpn) has emerged as an important cause of neonatal sepsis and is difficult to treat due to increasing antimicrobial resistance. Extended-spectrum beta-lactamases are enzymes that confer resistance to ceftriaxone, and for neonates in many sub-Saharan African neonatal units this resistance determinant renders their infections untreatable. While infection prevention and control (IPC) measures are important to limit transmission, the most important IPC measures in this context remain unclear. Added value of this studyThis study shows that colonisation with ESBL Kpn in the neonatal unit is common. Risk factors for colonisation include oxygen delivery, antibiotic therapy, and female gender. Isolates from invasive disease were genomically like those that caused stool colonisation and that were colonising the general ward environment. There was circulation of bacteria between the neonatal gastrointestinal tract, cots, mothers hands, and swaddling cloths. Transmission appeared to be from cots, ward surfaces, particularly sinks and oxygen equipment, other neonates, and the mothers hands. Implications of all available evidenceIPC should be prioritized to reduce colonisation and subsequent infection with ESBL Kpn, and other enteric pathogens regardless of AMR profile. Suggested IPC interventions in this context should focus on reducing bacterial load in the ward environment, with neonatal stool management, maternal hand hygiene, single-use oxygen delivery equipment, replacing sinks with hand sanitizer and cot decontamination.

BackgroundAn upsurge in Streptococcus pyogenes infections 2022-2023 highlighted potential benefits of point-of-care tests (POCT) to support clinical pathways, prevent outbreaks, and optimise antibiotic use. ObjectivesWe conducted a pilot research study in a west London paediatric emergency department (ED) to determine whether a molecular POCT had potential to alter management in children who were also having a conventional throat swab taken for culture. MethodsChildren <16 years presenting to ED who had a throat swab requested by a clinician were invited to have a second swab taken for research purposes only. Clinical management was unaffected by the research swab result, which was processed using a molecular POCT that was not approved for use in the host NHS Trust. ResultsPrevalence of streptococcal infection was low during the study (May 2023-June 2025); swab positivity in symptomatic children was 12.8% (6/47). Overall, 38/49 (77.6%) participants who had throat swabs received antibiotics. Of those children recommended to receive antibiotics, 29/38 (76.3%) had a negative POCT. Mean time to reporting of positive throat swab culture results was 3.67 days (range 3-5 days) leading to occasional delay in treatment, although POCT identified positive results within minutes. ConclusionAntibiotic use was frequent and could be avoided or stopped by use of a rule out POCT in over three-quarters of children in the ED, if suspicion of S. pyogenes is the main driver for prescribing. POCT were easy to process and produced immediate results compared with culture, in theory enabling timely decision-making and avoiding treatment delay.

Objectives To evaluate two-year, side-by-side outcomes of a prospective audit and feedback (PAF)-based antimicrobial stewardship program (ASP) in a quaternary ICU in Ghana, comparing diagnostic stewardship, antimicrobial prescribing patterns, and clinician adherence to stewardship recommendations between 2024 and 2025. Longitudinal PAF data from low- and middle-income countries (LMIC) quaternary ICUs are scarce; this study addresses that evidence gap. Methods A retrospective comparative analysis of routine Antimicrobial Stewardship (AMS) surveillance data was conducted at the University of Ghana Medical Centre ICU: 102 visits in 2024 and 63 in 2025. Proportions were compared by chi-square or Fishers exact test; continuous variables by Mann-Whitney U. Wilson score 95% confidence intervals (CIs) were computed for primary proportions. Results Biomarker-guided prescribing rose from 86.3% to 100% of visits (p=0.005) and culture and sensitivity testing from 74.5% to 90.5% (p=0.02). Targeted (culture-guided) therapy increased significantly from 23.5% to 41.7% of antibiotic recipients (p=0.03), while empiric prescribing declined correspondingly. Overall antibiotic utilization remained high in both years (96.1% vs 95.2%; p=1.00), and meropenem use rose from 42.9% to 56.7% (p=0.13). AMS interventions were recommended in 67.6% and 63.5% of visits, respectively. Clinician acceptance improved markedly from 40.6% (95% CI: 29.8-52.4%) to 67.5% (95% CI: 52.0-79.9%) (p=0.01). Conclusions Two years of PAF in a Ghanaian quaternary ICU demonstrated progressive program maturation: universal biomarker adoption, a significant shift toward targeted prescribing, and markedly enhanced clinician acceptance. Persistently high antibiotic utilization and rising carbapenem dependence underscore the need for sustained surveillance and carbapenem-sparing strategies in LMIC critical care.

Background Klebsiella pneumoniae (Kpn) is a major cause of neonatal sepsis in Africa. 3rd generation cephalosporin and gentamicin resistant Kpn is the norm in many sites, rendering WHO recommended first- and second-line antimicrobials ineffective. An understanding of which neonates and infants are most at risk of sepsis caused by Kpn would support the case for improved access to WHO watch and reserve antimicrobials (i.e. carbapenems) for patients most likely to benefit from them. Methods A prospective case-control study was conducted at Queen Elizabeth Central Hospital, Malawi. Cases were infants <3 months of age with blood or CSF culture confirmed Kpn infection. Controls were healthy infants from the same wards and were matched 2:1. Univariate and multivariate logistic regression were performed on mean-centred data to determine risk factors for infection with Kpn. Results We analysed data from 38 cases and 76 controls between August 2021 and April 2023. Mortality at 3 months of age was 21/38 (29%) for cases, with 14/38 (37%) identified postmortem and 6/76 (7.9%) for controls (OR 14.0 (95% CI 4.59, 49.2, p>0.001). Cases were more likely to be born out of QECH than controls (42% vs. 24%, p = 0.043), and cases had lower birthweights (median 2200g vs. 2850g, p = 0.005). Multivariate logistic regression analysis revealed that increasing birthweight was protective against Kpn infection (OR: 0.858 [95% CI: 0.745, 0.987] per 100g increase), while longer hospital stay was associated with increased odds of infection (OR: 1.148 [95% CI: 1.012, 1.1.303] per additional day). Most infecting isolates (34/38 [89%]) were resistant to first- and second-line antimicrobial agents, but all were sensitive to meropenem and 33/36 [92%] to amikacin. Conclusion Low birthweight infants with prolonged hospital stay were at greatest risk of Kpn infections that were typically resistant to WHO first- and second-line antimicrobial therapy. These infants should be prioritised for antibiotics that have the potential to be life-saving. The overlapping and evolving nature of these risk factors makes it difficult to design a simple tool to support empiric initiation of meropenem. Neonates critically ill with Kpn sepsis cannot, however, afford to wait for blood culture confirmation before receiving effective treatment. This highlights the need for empiric decision making frameworks that allow rapid initiation of effective therapy in high-risk neonates.

Antimicrobial resistance (AMR) to all antibiotic classes has been found in the pathogen Staphylococcus aureus. The reported prevalence of these resistances vary, driven by within-host AMR evolution at the patient level, and between-host transmission at the hospital level. Without dense longitudinal sampling, pragmatic analysis of AMR dynamics at multiple levels using routine surveillance data is essential to inform control measures. We explored S. aureus AMR diversity in 70,000 isolates from a UK paediatric hospital between 2000-2020, using electronic datasets containing multiple routinely collected isolates per patient with phenotypic antibiograms, hospitalisation information, and antibiotic consumption. At the hospital-level, the proportion of isolates that were meticillin-resistant (MRSA) increased between 2014-2020 from 25 to 50%, before sharply decreasing to 30%, likely due to a change in inpatient demographics. Temporal trends in the proportion of isolates resistant to different antibiotics were often correlated in MRSA, but independent in meticillin-susceptible S. aureus. Ciprofloxacin resistance in MRSA decreased from 70% to 40% of tested isolates between 2007-2020, likely linked to a national policy to reduce fluoroquinolone usage in 2007. At the patient level, we identified frequent AMR diversity, with 4% of patients ever positive for S. aureus simultaneously carrying, at some point, multiple isolates with different resistances. We detected changes over time in AMR diversity in 3% of patients ever positive for S. aureus. These changes equally represented gain and loss of resistance. Within this routinely collected dataset, we found that 65% of changes in resistance within a patients S. aureus population could not be explained by antibiotic exposure or between-patient transmission of bacteria, suggesting that within-host evolution via frequent gain and loss of AMR genes may be responsible for these changing AMR profiles. Our study highlights the value of exploring existing routine surveillance data to determine underlying mechanisms of AMR. These insights may substantially improve our understanding of the importance of antibiotic exposure variation, and the success of single S. aureus clones.

IntroductionDisease surveillance is an essential element of an effective response to antimicrobial resistance (AMR). Associations between AMR cases and area-level drivers such as remoteness and socio-economic disadvantage have been observed, but spatial associations when modelling routinely collected surveillance data that are often imperfect or missing have not been previously possible. AimWe aimed to use spatial modelling to adjust for area-level variables and to enhance AMR surveillance for missing or sparse data, in an effort to provide clinicians and policy makers with more actionable epidemiological information. MethodsWe used monthly antimicrobial susceptibility data for methicillin-resistant Staphylococcus aureus (MRSA) from a surveillance system in Australia. MRSA was assessed for the effects of age, sex, socio-economic and access to healthcare services indices by fitting Bayesian spatial models. ResultsWe analysed data for 77, 760 MRSA isolates between 2016 and 2022. We observed significant spatial heterogeneity in MRSA and found significant associations with age, sex and remoteness, but not socio-economic status. MRSA infections were highest in adult females aged 16-60 living in very remote regions and lowest in senior males aged 60+ years living in inner regional areas.. ConclusionCurrent disease surveillance approaches for antimicrobial resistant infections have limited spatial comparability, are not timely, and at risk of sampling bias. Bayesian spatial models borrow information from neighbouring regions to adjust for unbalanced geographical information and can fill information gaps of current MRSA surveillance. Assessment of disease spatial variation is especially critical in settings which have diverse geography, dispersed populations or in regions with limited microbiological capacity.