Stephan Harbarth

University of Geneva, Genève, Geneva, Switzerland

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Publications (203)1315.74 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Predictive models to identify unknown methicillin-resistant Staphylococcus aureus (MRSA) carriage on admission may optimise targeted MRSA screening and efficient use of resources. However, common approaches to model selection can result in overconfident estimates and poor predictive performance. We aimed to compare the performance of various models to predict previously unknown MRSA carriage on admission to surgical wards. The study analysed data collected during a prospective cohort study which enrolled consecutive adult patients admitted to 13 surgical wards in 4 European hospitals. The participating hospitals were located in Athens (Greece), Barcelona (Spain), Cremona (Italy) and Paris (France). Universal admission MRSA screening was performed in the surgical wards. Data regarding demographic characteristics and potential risk factors for MRSA carriage were prospectively collected during the study period. Four logistic regression models were used to predict probabilities of unknown MRSA carriage using risk factor data: "Stepwise" (variables selected by backward elimination); "Best BMA" (model with highest posterior probability using Bayesian model averaging which accounts for uncertainty in model choice); "BMA" (average of all models selected with BMA); and "Simple" (model including variables selected >50% of the time by both Stepwise and BMA approaches applied to repeated random sub-samples of 50% of the data). To assess model performance, cross-validation against data not used for model fitting was conducted and net reclassification improvement (NRI) was calculated. Of 2,901 patients enrolled, 111 (3.8%) were newly identified MRSA carriers. Recent hospitalisation and presence of a wound/ulcer were significantly associated with MRSA carriage in all models. While all models demonstrated limited predictive ability (mean c-statistics <0.7) the Simple model consistently detected more MRSA-positive individuals despite screening fewer patients than the Stepwise model. Moreover, the Simple model improved reclassification of patients into appropriate risk strata compared with the Stepwise model (NRI 6.6%, P = .07). Though commonly used, models developed using stepwise variable selection can have relatively poor predictive value. When developing MRSA risk indices, simpler models, which account for uncertainty in model selection, may better stratify patients' risk of unknown MRSA carriage.
    BMC Infectious Diseases 12/2015; 15(1):834. DOI:10.1186/s12879-015-0834-y · 2.56 Impact Factor
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    ABSTRACT: The objective was to study changes in the faecal microbiota of patients with uncomplicated urinary tract infections (UTIs) treated with nitrofurantoin and of non-treated healthy controls using 16S rRNA analysis. Serial stool samples were collected from patients receiving nitrofurantoin treatment at different timepoints [before treatment (day 1; T1), within 48 h of end of treatment (days 5-15; T2) and 28 days after treatment (days 31-43; T3)], as well as from healthy controls. Direct DNA extraction (PowerSoil DNA Isolation Kit, MoBio Laboratories, Carlsbad, CA, USA) from stool samples was followed by pyrosequencing (454 GS FLX Titanium) of the V3-V5 region of the bacterial 16S rRNA gene. Among UTI patients, mean proportions of the Actinobacteria phylum increased by 19.6% in the first follow-up sample (T2) in comparison with the pretreatment baseline stool sample (T1) (P = 0.026). However, proportions of Actinobacteria reversed to 'normal' pre-antibiotic levels, with a mean difference of 1.0% compared with baseline proportions, in the second follow-up sample (T3). The increase in Actinobacteria was specifically due to an increase in the Bifidobacteriaceae family (Bifidobacterium genus), which constituted 81.0% (95% CI ±7.4%) of this phylum. No significant impact was observed other than a temporary increase in the beneficial Bifidobacterium genus following nitrofurantoin treatment, which supports its reintroduction into clinical use. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail:
    Journal of Antimicrobial Chemotherapy 03/2015; DOI:10.1093/jac/dkv062 · 5.44 Impact Factor
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    ABSTRACT: Whilst augmented renal clearance (ARC) is associated with reduced β-lactam plasma concentrations, its impact on clinical outcomes is unclear. This single-centre prospective, observational, cohort study included non-pregnant, critically ill patients aged 18–60 years with presumed severe infection treated with imipenem, meropenem, piperacillin/tazobactam or cefepime and with creatinine clearance (CLCr) ≥60 mL/min. Peak, intermediate and trough levels of β-lactams were drawn on Days 1–3 and 5. Concentrations were deemed ‘subthreshold’ if they did not meet EUCAST-defined non-species-related breakpoints. Primary and secondary endpoints were clinical response 28 days after inclusion, and ARC prevalence (CLCr ≥ 130 mL/min) and subthreshold and undetectable concentrations, respectively. Logistic regression was used to evaluate associations between ARC, antibiotic concentrations and clinical failure. From 2010 to 2013, 100 patients were enrolled (mean age, 45 years; median CLCr at inclusion, 144.1 mL/min). ARC was present in 64 (64%) of the patients. Most patients received imipenem/cilastatin (54%). Moreover, 86% and 27% of patients had at least one subthreshold or undetectable trough level, respectively. Among imipenem and piperacillin trough levels, 77% and 61% were subthreshold, respectively, but intermediate levels of both antibiotics were largely above threshold. ARC strongly predicted undetectable trough concentrations (OR = 3.3, 95% CI 1.11–9.94). A link between ARC and clinical failure (18/98; 18%) was not observed. ARC and subthreshold β-lactam antibiotic concentrations were widespread but were not associated with clinical failure. Larger studies are necessary to determine whether standard dosing regimens in the presence of ARC impact negatively on clinical outcome and antibiotic resistance.
    International Journal of Antimicrobial Agents 01/2015; DOI:10.1016/j.ijantimicag.2014.12.017 · 4.26 Impact Factor
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    ABSTRACT: The objective of this review was to provide an up-to-date account of the interventions used to prevent the introduction of meticillin-resistant Staphylococcus aureus (MRSA) from the expanding community and livestock reservoirs into hospitals in the USA, Denmark, The Netherlands and Western Australia. A review of existing literature and local guidelines for the management of MRSA in hospitals was performed. In Denmark, The Netherlands and Western Australia, where the prevalence of MRSA is relatively low, targeted admission screening and isolation of predefined high-risk populations have been used for several decades to successfully control MRSA in the hospital. Furthermore, in Denmark and The Netherlands, all identified MRSA carriers undergo routine decolonisation, whereas only carriers of particularly transmissible or virulent MRSA clones are subjected to decolonisation in Western Australia. In the USA, which continues to be a high-prevalence MRSA country, policies vary by state and even by hospital, and whilst guidelines from professional organisations provide a framework for infection control practices, these guidelines lack the authority of a legislative mandate. In conclusion, the changing epidemiology of MRSA, exemplified by the recent emergence of MRSA in the community and in food animals, makes it increasingly difficult to accurately identify specific high-risk groups to screen for MRSA carriage. Understanding the changing epidemiology of MRSA in a local as well as global context is fundamental to prevent the introduction of MRSA into hospitals.
    12/2014; DOI:10.1016/j.jgar.2014.09.003
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    ABSTRACT: The best treatment for Tropheryma whipplei infections is controversial. We report a patient who suffered from T. whipplei aortic native valve endocarditis that relapsed despite surgery and four weeks of intravenous ceftriaxone followed by several months of oral trimethoprim/sulfamethoxazole. Cure was achieved after replacement of the prosthesis with a homograft and 18 months of oral doxycycline-hydroxychloroquine. We discuss the need for a change in treatment guidelines for T. whipplei infections. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
    International Journal of Infectious Diseases 11/2014; 30C:17-19. DOI:10.1016/j.ijid.2014.11.003 · 2.33 Impact Factor
  • K Stucki, S Harbarth, M Nendaz
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    ABSTRACT: Enterococci are microorganisms with a remar- kable ability to adapt to their environment. Two species have a significant clinical implication, Enterococcus faecalis and Enterococcus faecium. The risk factors for colonization and infection must be recognized, including prior treatment with antibiotics such as cephalosporins or quinolones. Because of their native resistance to several classes of antibiotics and the increase of acquired resistance to penicillins, the initial empiric treatment of a severe infection in a patient at risk of enterococcal infection often includes a glycopeptide. A restriction in the empirical use of cephalosporins or quinolones and a targeted antibiotic therapy following receipt of the antibiogram are essential to prevent the emergence of enterococcal strains and especially vancomycin-resistant enterococci.
  • Benedikt Huttner, Stephan Harbarth, Dilip Nathwani
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    ABSTRACT: It has been increasingly recognized that antimicrobial stewardship (AMS) has to be a key component of any efforts that aim to mitigate the current global antimicrobial resistance (AMR) crisis. It has also become evident that AMR is a problem that cannot be tackled by single institutions or physicians, but needs concerted actions on the regional, national and supranational level. It is, however, easy to become discouraged given the problems that are often encountered when implementing AMS. The aim of this review is to highlight some of the success stories of AMS strategies, to describe the actions that have been taken, the outcomes that have been obtained and the obstacles that have been met. While the best approach to effective AMS remains elusive and may significantly vary among settings, these diverse examples from a range of health care contexts demonstrate that effective AMS is possible. The learning from such examples will inform and encourage others to formally evaluate and share their results with the global stewardship community. This article is protected by copyright. All rights reserved.
    Clinical Microbiology and Infection 10/2014; 20(10). DOI:10.1111/1469-0691.12803 · 5.20 Impact Factor
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    ABSTRACT: IMPORTANCE The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial. OBJECTIVE To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation. INTERVENTIONS Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm. MAIN OUTCOMES AND MEASURES Proportion of patients not reaching clinical stability (heart rate <100/min, systolic blood pressure >90mmHg, temperature <38.0°C, respiratory rate <24/min, and oxygen saturation >90% on room air) at day 7. RESULTS After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6%difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95%CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95%CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95%CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95%CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9%vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms. CONCLUSIONS AND RELEVANCE We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy.
    JAMA Internal Medicine 10/2014; DOI:10.1001/jamainternmed.2014.4887 · 13.25 Impact Factor
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    ABSTRACT: We performed a contingent valuation survey to elicit the opportunity cost of bed-days consumed by healthcare-associated infections in 11 European hospitals. The opportunity cost of a bed-day was significantly lower than the accounting cost; median values were €72 and €929, respectively (P < .001). Accounting methods overestimate the opportunity cost of bed-days.
    Infection Control and Hospital Epidemiology 10/2014; 35(10):1294-1297. DOI:10.1086/678063 · 3.94 Impact Factor
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    ABSTRACT: Nitrofurantoin has been used for decades for the treatment of urinary tract infections (UTI), however, clinically significant resistance in E. coli is as yet uncommon. Nitrofurantoin concentrations in the gastrointestinal tract tend to be low, which might facilitate selection of nitrofurantoin-resistant (NIT-R) strains in the gut flora. We subjected two nitrofurantoin-susceptible intestinal E. coli strains (ST540-p, ST2747-p) to increasing nitrofurantoin concentrations under aerobic and anaerobic conditions. Whole genome sequencing was performed on both susceptible isolates and on selected mutants that exhibited the highest nitrofurantoin resistance levels aerobically (ST540-a, ST2747-a) and anaerobically (ST540-an, ST2747-an). ST540-a/-an and ST2747-a (aerobic MIC >64 μg/ml) harbored mutations in known nitrofurantoin resistance determinants, nfsA and/or nfsB that encode oxygen-insensitive nitroreductases. ST2747-an showed reduced nitrofurantoin susceptibility (aerobic MIC 32 μg/ml) and exhibited remarkable growth deficits, however, did not harbor nfsA/B mutations. We identified a 12-nucleotide deletion in ribE encoding lumazine synthase, an essential enzyme involved in the biosynthesis of FMN, an important cofactor of NfsA/B. Complementing ST2747-an with a functional wild-type lumazine synthase restored nitrofurantoin susceptibility. Six NIT-R E. coli (NRCI-1 to -6) isolated from stools of UTI patients treated with nitrofurantoin, cefuroxime, or a fluoroquinolone harbored mutations in nfsA and/or nfsB, but not in ribE. Sequencing of the ribE gene in six intestinal and three urinary E. coli strains showing reduced nitrofurantoin-susceptibility (MIC range 16-48 μg/ml) also did not identify any relevant mutations. NRCI-1, -2, -5 exhibited upto four-fold higher anaerobic MICs compared to the in vitro mutants, presumably because of additional mutations in oxygen-sensitive nitroreductases.
    Antimicrobial Agents and Chemotherapy 09/2014; 58(12). DOI:10.1128/AAC.03952-14 · 4.45 Impact Factor
  • Jean-Francois Timsit, Stephan Harbarth, Jean Carlet
    Intensive Care Medicine 09/2014; 40(10). DOI:10.1007/s00134-014-3485-3 · 5.54 Impact Factor
  • Gerd Fätkenheuer, Bernard Hirschel, Stephan Harbarth
    The Lancet 08/2014; DOI:10.1016/S0140-6736(14)60660-7 · 39.21 Impact Factor
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    ABSTRACT: Topical mupirocin is widely used for the decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers. We evaluated the capacity of various MRSA clonotypes to develop mutations in the ileS gene associated with low-level mupirocin resistance. Twenty-four mupirocin-sensitive MRSA isolates from a variety of genotypes (determined by multilocus variable number of tandem repeats assay) were selected. Mupirocin MICs were determined by Etest. The isolates were then incubated in sub-inhibitory concentrations of mupirocin for 7-14 days. Repeat MIC determination and sequencing of the ileS gene were then performed. Doubling times of isolates exposed and unexposed to mupirocin were compared. We found that exposure to mupirocin led to rapid induction of low-level resistance (MICs 8-24 μg/ml) in 11 of 24 (46%) MRSA isolates. This phenomenon was observed in strains with diverse genetic backgrounds. Various mutations were detected in 18 of 24 (75%) MRSA isolates. Acquisition of mutations appeared to be a stepwise process during prolonged incubation with the drug. Among five low-level resistant isolates with the highest MICs, four tested sensitive after incubation in the absence of mupirocin but there was no reversion to the susceptible wild-type primary sequence. Resistance was not associated with significant fitness cost, suggesting that low-level mupirocin-resistant MRSA strains may have a selective advantage in facilities where mupirocin is commonly used. Our findings emphasize the importance of the judicious use of this topical agent and the need to closely monitor for the emergence of resistance.
    Journal of Clinical Microbiology 08/2014; 52(10). DOI:10.1128/JCM.01010-14 · 4.23 Impact Factor
  • Kalisvar Marimuthu, Stephan Harbarth
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    ABSTRACT: To describe the latest evidence for methicillin-resistant Staphylococcus aureus (MRSA) infection control strategies, with particular emphasis on active surveillance cultures with contact precautions and targeted decolonization, and their impact.
    Current Opinion in Infectious Diseases 08/2014; 27(4):356-362. DOI:10.1097/QCO.0000000000000081 · 5.03 Impact Factor
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    ABSTRACT: Purpose of review The prevalence of multidrug-resistant organisms (MDROs) in ICUs is increasing worldwide. This review assesses the role of infection control measures, excluding antibiotic stewardship programs, in reducing the burden of resistance in ICUs. Recent findings The knowledge base about the effect of increased hand hygiene compliance in reducing the burden of methicillin-resistant Staphylococcus aureus in ICUs has been improved. Universal decolonization with chlorhexidine body washing was associated with significant reduction in MDRO prevalence, but vigilance for emerging chlorhexidine resistance is required. A significant reduction of resistance for Gram-negative bacilli has been demonstrated with the use of selective decontamination, but further clinical trials are necessary before definitive conclusions can be drawn regarding long-term risk/benefit ratios. Summary In the recent years, several high-quality clinical studies have assessed the ability of various infection control measures in reducing the burden of antimicrobial resistance. Significant progress has been made in identifying interventions effective in preventing transmission of MDROs in ICUs, in particular, decolonization. However, it still remains impossible to determine the exact and relative importance of different infection control measures. Any approach must ultimately be tailored to the local epidemiology of the targeted ICU.
    Current Opinion in Critical Care 07/2014; 20(5). DOI:10.1097/MCC.0000000000000126 · 3.18 Impact Factor
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    ABSTRACT: Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of utmost importance. We present here a narrative review of the impact of infectious diseases specialists (IDS) on the quality and quantity of antibiotic use in acute care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings and types of antibiotic prescriptions. Seven of 31 studies were randomised controlled trials, before/after controlled studies or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement of the appropriateness of antibiotic prescribing compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDS, informal (curbside) consultations, involvement of junior IDS are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDS in acute care hospitals that are rarely reported in the published literature. Overall, IDS are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organisational factors.This article is protected by copyright. All rights reserved.
    Clinical Microbiology and Infection 07/2014; 20(10). DOI:10.1111/1469-0691.12751 · 5.20 Impact Factor
  • Future Microbiology 06/2014; 9(6):757-771. DOI:10.2217/fmb.14.35 · 3.82 Impact Factor
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    ABSTRACT: Objective. To test the hypothesis that methicillin-susceptible Staphylococcus aureus (MSSA) carriage may protect against nosocomial methicillin-resistant S. aureus (MRSA) acquisition by competing for colonization of the anterior nares. Design. Prospective cohort and nested case-control study. Setting. Swiss university hospital. Patients. All adult patients admitted to 14 wards of the general medicine division between April 1 and October 31, 2007. Methods. Patients were screened for MRSA and MSSA carriage at admission to and discharge from the division. Associations between nosocomial MRSA acquisition and MSSA colonization at admission and other confounders were analyzed by univariable and multivariable analysis. Results. Of 898 patients included, 183 (20%) were treated with antibiotics. Nosocomial MRSA acquisition occurred in 70 (8%) of the patients (case patients); 828 (92%) of the patients (control subjects) were free of MRSA colonization at discharge. MSSA carriage at admission was 20% and 21% for case patients and control subjects, respectively. After adjustment by multivariate logistic regression, no association was observed between MSSA colonization at admission and nosocomial MRSA acquisition (adjusted odds ratio [aOR], 1.2 [95% confidence interval (CI), 0.6-2.3]). By contrast, 4 independent predictors of nosocomial MRSA acquisition were identified: older age (aOR per 1-year increment, 1.05 [95% CI, 1.02-1.08]); increased length of stay (aOR per 1-day increment, 1.05 [95% CI, 1.02-1.09]); increased nursing workload index (aOR per 1-point increment, 1.02 [95% CI, 1.01-1.04]); and previous treatment with macrolides (aOR, 5.6 [95% CI, 1.8-17.7]). Conclusions. Endogenous MSSA colonization does not appear to protect against nosocomial MRSA acquisition in a population of medical patients without frequent antibiotic exposure.
    Infection Control and Hospital Epidemiology 05/2014; 35(5):527-33. DOI:10.1086/675825 · 3.94 Impact Factor
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    ABSTRACT: Risk factor analyses for nosocomial infections (NIs) are complex. First, due to competing events for NI, the association between risk factors of NI as measured using hazard rates may not coincide with the association using cumulative probability (risk). Second, patients from the same intensive care unit (ICU) who share the same environmental exposure are likely to be more similar with regard to risk factors predisposing to a NI than patients from different ICUs. We aimed to develop an analytical approach to account for both features and to use it to evaluate associations between patient- and ICU-level characteristics with both rates of NI and competing risks and with the cumulative probability of infection. Methods: We considered a multi-center data base of 159 intensive care units containing 10,9216 admissions (71,0221 admission-days) from the Spanish HELICS-ENVIN ICU network. We analysed the data using two models: an etiologic model (rate-based) and a predictive model (risk-based). In both models, random effects (shared frailties) are introduced to assess heterogeneity. Death and discharge without NI are treated as competing events for NI. Results: There was a large heterogeneity across ICUs in NI hazard rates which remained after accounting for multilevel risk factors, meaning that there are remaining unobserved ICU-specific factors which influence NI occurrence. Heterogeneity across ICUs in terms of cumulative probability of NI was even more pronounced. Several risk factors had markedly different associations in the rate-based and risk-based models. For some the associations differed in magnitude. For example high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were associated with modest increases in the rate of NB, but large increases in the risk. Others differed in sign, for example respiratory versus cardiovascular diagnostic categories were associated with reduced rate of NB, but an increased risk. Conclusions: A combination of competing risks and multilevel models is required to understand direct and indirect risk factors for NI and distinguish patient-level from ICU-level factors.
    Critical care (London, England) 04/2014; 18(2):R64. DOI:10.1186/cc13821
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    ABSTRACT: Objective. Determine the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) contamination of food and colonization of food handlers in a hospital kitchen and compare retrieved ESBL-PE strains with patient isolates. Design. Cross-sectional study. Setting. A 2,200-bed tertiary care university hospital in Switzerland. Participants. Food handlers. Methods. Raw and prepared food samples were obtained from the hospital kitchen, with a comparator group from local supermarkets. Fecal samples collected from food handlers and selectively pre-enriched homogenized food samples were inoculated onto selective chromogenic media. Phenotypic confirmation of ESBL production was performed using the double disk method. Representative ESBL-PE were characterized using polymerase chain reaction (PCR) and sequencing for blaCTX-M, blaSHV, and blaTEM genes, and Escherichia coli strains were typed using phylotyping, repetitive element palindromic PCR, and multilocus sequence typing. Meat samples were screened for antibiotic residues using liquid chromatography time-of-flight mass spectrometry. Results. Sixty (92%) of the raw chicken samples were ESBL-PE positive, including 30 (86%) of the hospital samples and all supermarket samples. No egg, beef, rabbit, or cooked chicken samples were ESBL-PE positive. No antibiotic residues were detected. Six (6.5%) of 93 food handlers were ESBL-PE carriers. ESBL-PE strains from chicken meat more commonly possessed blaCTX-M-1 and blaCTX-M-2, whereas blaCTX-M-14 and blaCTX-M-15 were predominant among strains of human origin. There was partial overlap in the sequence type of E. coli strains of chicken and human origin. No E. coli ST131 strains or blaCTX-M-15 genes were isolated from meat. Conclusions. Although there is significant ESBL-PE contamination of delivered chicken meat, current preventive strategies minimize risks to food handlers, hospital staff, and patients.
    Infection Control and Hospital Epidemiology 04/2014; 35(4):375-83. DOI:10.1086/675609 · 3.94 Impact Factor

Publication Stats

9k Citations
1,315.74 Total Impact Points


  • 1999–2015
    • University of Geneva
      • • Faculty of Medicine
      • • Division of Infectious Diseases
      • • Division of Geriatrics
      • • Department of Internal Medicine
      Genève, Geneva, Switzerland
  • 1998–2014
    • Hôpitaux Universitaires de Genève
      Genève, Geneva, Switzerland
  • 2011
    • University of Pennsylvania
      Philadelphia, Pennsylvania, United States
  • 2002–2010
    • University of Utah
      • • Division of Epidemiology
      • • Department of Internal Medicine
      • • Division of Infectious Diseases
      Salt Lake City, UT, United States
  • 2006
    • Universitätsspital Basel
      • Klinik für Infektiologie & Spitalhygiene
      Bâle, Basel-City, Switzerland
  • 2005
    • Hospital of Saint Raphael
      New Haven, Connecticut, United States
  • 2001–2002
    • Boston Children's Hospital
      • Division of Infectious Diseases
      Boston, Massachusetts, United States
  • 1998–2001
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 1999–2000
    • Harvard University
      • Department of Epidemiology
      Cambridge, Massachusetts, United States