Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control

Antecedent Carbapenem Exposure as a Risk Factor for Non-Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae and Carbapenemase-Producing Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CRE) can be mechanistically classified into carbapenemase-producing Enterobacteriaceae (CPE) and non-carbapenemase-producing carbapenem nonsusceptible Enterobacteriaceae (NCPCRE). We sought to investigate the effect of antecedent carbapenem exposure as a risk factor for NCPCRE versus CPE. Among all patients with CRE colonization and infection, we conducted a case-control study comparing patients with NCPCRE (cases) and patients with CPE (controls). The presence of carbapenemases was investigated with phenotypic tests followed by PCR for predominant carbapenemase genes. We included 843 unique patients with first-episode CRE, including 387 (45.9%) NCPCRE and 456 (54.1%) CPE. The resistance genes detected in CPEs were bla _NDM (42.8%), bla _KPC (38.4%), and bla _OXA-48-like (12.1%). After adjusting for confounders and clustering at the institutional level, the odds of prior 30-day carbapenem exposure was three times higher among NCPCRE than CPE patients (adjusted odds ratio [aOR], 3.48; 95% confidence interval [CI], 2.39 to 5.09; P < 0.001). The odds of prior carbapenem exposure and NCPCRE detection persisted in stratified analyses by Enterobacteriaceae species (Klebsiella pneumoniae and Escherichia coli) and carbapenemase gene (bla _NDM and bla _KPC). CPE was associated with male gender (aOR, 1.45; 95% CI, 1.07 to 1.97; P = 0.02), intensive care unit stay (aOR, 1.84; 95% CI, 1.24 to 2.74; P = 0.003), and hospitalization in the preceding 1 year (aOR, 1.42; 95% CI, 1.01 to 2.02; P = 0.05). In a large nationwide study, antecedent carbapenem exposure was a significant risk factor for NCPCRE versus CPE, suggesting a differential effect of antibiotic selection pressure.

Active surveillance culture program in asymptomatic patients as a strategy to control multidrug-resistant gram-negative organisms: What should be considered?

The increasing burden of multidrug-resistant gram-negative bacilli (MDR-GNB) infection has highlighted the urgent requirement for efficient prevention and control strategies. A routine active surveillance culture (ASC) program of asymptomatic carriers as part of an infection prevention strategy for MDR-GNB still has some controversy. An ASC program for colonized patients may be beneficial depending on the targeted population, level of endemicity, the species of pathogen, and the combination of multifaceted strategies. Multimodal infection control and prevention strategies are crucial for implementation in resources-limited settings. After discovering the culprit, it is a challenge to control MDR-GNB by containment or eradication and prevent cross-transmission. An ASC program should consider both the local epidemiology and cost-effectiveness based on the available resources in endemic MDR-GNB areas in the Asia-Pacific region.

VIM-carbapenemase-producing Escherichia coli in a residential care home in The Netherlands

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) are an important and increasing threat to public health. In hospitals and long-term care facilities, carriers should be identified to prevent transmission; however, guidelines for infection control are not applicable to all types of care homes.

AIM

To report the outbreak investigation of a VIM-metallo-β-lactamase-producing Escherichia coli in a Dutch residential care home, where residents lived in private apartments but also used shared facilities.

METHODS

Contact and environmental screening rounds were performed to assess carriage and colonization rates. Due to the domestic characteristics of the home, customized infection control measures were needed. A bundle of interventions was implemented, including contact precautions, improved hygiene and education.

FINDINGS

In total, eight CPE carriers, including the index case, were identified among 110 residents. VIM-CPE spread was associated with the use of shared toilets in communal areas. Seven months after the first finding, all carriers were found to be VIM-negative, and after 1 year, VIM CPE was no longer detectable in the environment.

CONCLUSION

A customized bundled approach was needed to control the outbreak successfully. Current guidelines should be adapted to be suitable for all types of residential care homes in order to combat the spread of multi-resistant pathogens effectively.

Screening for carriage of carbapenem-resistant Enterobacteriaceae in settings of high endemicity: a position paper from an Italian working group on CRE infections

Introduction

A variety of national and international guidelines exist around the management of carbapenem resistant Enterobacteriaceae (CREs), but some of these are several years old and do not reflect current epidemiology and they also do not necessarily give pragmatic advice around active surveillance of CREs in countries with a high burden of cases and limited resources. This paper aims to provide a best practice position paper to guide active surveillance in a variety of scenarios in these settings, and discusses which patients should be screened, what methods could be used for screening, and how results might influence infection prevention interventions.

Methods

This paper was developed as a result of a series of meetings of expert opinion leaders representing the major infectious disease and infection prevention societies in Italy and having the endorsement of AMCLI (Italian Association of Clinical Microbiology) and SITA (Italian Society for Anti-infective Therapy). There was no attempt to undertake a full systematic review of the evidence, as it was felt that this was inadequate to inform a pragmatic view on the best way forward based on current epidemiology and infection rates.

Key recommendations

Key recommendations focus on the urgent need to promote measures to prevent transmission and infection, focusing on high risk patients and clinical areas, as well as outbreak situations. Active surveillance leading to appropriate infection prevention precautions plays a major role in this.

Conclusions

There are limited national or international guidelines giving pragmatic advice on the most appropriate measures for active surveillance and management of colonized patients in a high-burden setting such as Italy. While individual hospitals and regions will need to formulate their own policies based on local epidemiology, this position paper attempts to highlight current best practice in this area and provide pragmatic advice for clinicians, infection prevention staff, and healthcare managers.

The Gut Microbiota in Causation, Detection, and Treatment of Cancer

The gut microbiota has emerged as an important consideration in clinical oncology. The role of the microbiome in cancer extends beyond causation and cancer risk. It is now known that the microbiome not only acts at a local epithelial level in the gut but also modifies immune responses within intestinal and extraintestinal tumors. Microbial signaling influences the clinical course of cancer including the efficacy, bioavailability, and toxicity of chemotherapeutic and immunotherapy agents. This has focused research on microbiota profiling in different cancer states with an aim of developing prognostic biomarkers of risk. The potential value of microbiome manipulation with live biotherapeutics or microbial transplantation has also become a realistic consideration. Maintenance of microbial diversity in patients with cancer is a variable challenge given the modifying influences of the tumor itself, chemotherapy, nutritional status, and sporadic antimicrobial therapy. Here, we address current evidence for the role of the microbiome in cancer therapy.

Emergence of NDM-4-producing Klebsiella pneumoniae in a Korean hospital due to a patient hospitalized in Vietnam and case review

NDM-4-producing Klebsiella pneumoniae (NDM-4-KP) was detected from the patient who had previously been injured and hospitalized for 5 days in Vietnam in a neurosurgical intensive care unit (NSICU) of a Korean tertiary-care hospital in December 2016. He admitted with ventilator-associated pneumonia and NDM-4-KP was isolated, which was subsequently detected in two other NSICU patients. All NDM-4-KP isolates from patient and environmental surveillance cultures were sequence type 11. Colonization of three patients persisted for 5-12 months. Dedicated environmental cleaning was added to single room isolation of NDM-4-KP patients and universal chlorhexidine bathing, and no further transmission of NDM-4-KP occurred. This is the first report of NDM-4-KP in a Korean hospital where a patient with a history of hospitalization abroad was the index case initiating an outbreak involving three patients. The spread of newly introduced CPE was controlled using a bundle of infection control.

Biofilm formation by multidrug resistant Enterobacteriaceae strains isolated from solid organ transplant recipients

Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant bacteria (MDR). In this study, the biofilm-forming capability of 209 MDR strains (Escherichia coli n = 106, Klebsiella pneumoniae n = 78, and Enterobacter spp. n = 25) isolated from rectal swabs in the first 48 hours before or after kidney (93 patients), liver (60 patients) or kidney/pancreas transplants (5 patients) were evaluated by using a microplate assay. Thirty-nine strains were isolated before transplant and 170 strains were isolated post-transplant. Overall, 16% of E. coli strains, 73% of K. pneumoniae strains and 4% Enterobacter strains showed moderate or strong biofilm production. Nine strains isolated from infection sites after transplantation were responsible of infections in the first month. Of these, 4 K. pneumoniae, 1 E. coli and 1 Enterobacter spp. strains isolated pre-transplant or post-transplant as colonizers caused infections in the post-transplant period. Our results suggest that in vitro biofilm formation could be an important factor for adhesion to intestine and colonization in MDR K. pneumoniae strains in SOT recipients, but this factor appears to be less important for MDR E. coli and Enterobacter spp.

Persisting intrahospital transmission of multidrug-resistant Klebsiella pneumoniae and challenges for infection control

In the past several decades, the incidence of Klebsiella pneumoniae harboring resistance mechanisms against multiple antibiotic agents has increased on a global scale. We discuss reasons for ongoing transmission of multidrug-resistant K. pneumoniae in healthcare settings, which has resulted in the successful spread and establishment of this pathogen. It is now one of the most important causes of healthcare-associated infections worldwide.

Carbapenemase-producing bacteria in food-producing animals, wildlife and environment: A challenge for human health

Antimicrobial resistance is an increasing global health problem and one of the major concerns for economic impacts worldwide. Recently, resistance against carbapenems (doripenem, ertapenem, imipenem, meropenem), which are critically important antimicrobials for human cares, poses a great risk all over the world. Carbapenemases are β-lactamases belonging to different Ambler classes (A, B, D) and encoded by both chromosomal and plasmidic genes. They hydrolyze a broad variety of β-lactams, including carbapenems, cephalosporins, penicillins and aztreonam. Despite several studies in human patients and hospital settings have been performed in European countries, the role of livestock animals, wild animals and the terrestrial and aquatic environment in the maintenance and transmission of carbapenemase- producing bacteria has been poorly investigated. The present review focuses on the carbapenemase-producing bacteria detected in pigs, cattle, poultry, fish, mollusks, wild birds and wild mammals in Europe as well as in non-European countries, investigating the genetic mechanisms for their transmission among food-producing animals and wildlife. To shed light on the important role of the environment in the maintenance and genetic exchange of resistance determinants between environmental and pathogenic bacteria, studies on aquatic sources (rivers, lakes, as well as wastewater treatment plants) are described.

High prevalence of colonisation with carbapenem-resistant Enterobacteriaceae among patients admitted to Vietnamese hospitals: Risk factors and burden of disease

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) is an increasing problem worldwide, but particularly problematic in low- and middle-income countries (LMIC) due to limitations of resources for surveillance of CRE and infection prevention and control (IPC).

METHODS

A point prevalence survey (PPS) with screening for colonisation with CRE was conducted on 2233 patients admitted to neonatal, paediatric and adult care at 12 Vietnamese hospitals located in northern, central and southern Vietnam during 2017 and 2018. CRE colonisation was determined by culturing of faecal specimens on selective agar for CRE. Risk factors for CRE colonisation were evaluated. A CRE admission and discharge screening sub-study was conducted among one of the most vulnerable patient groups; infants treated at an 80-bed Neonatal ICU from March throughout June 2017 to assess CRE acquisition, hospital-acquired infection (HAI) and treatment outcome.

RESULTS

A total of 1165 (52%) patients were colonised with CRE, most commonly Klebsiella pneumoniae (n = 805), Escherichia coli (n = 682) and Enterobacter spp. (n = 61). Duration of hospital stay, HAI and treatment with a carbapenem were independent risk factors for CRE colonisation. The PPS showed that the prevalence of CRE colonisation increased on average 4.2% per day and mean CRE colonisation rates increased from 13% on the day of admission to 89% at day 15 of hospital stay. At the NICU, CRE colonisation increased from 32% at admission to 87% at discharge, mortality was significantly associated (OR 5·5, P < 0·01) with CRE colonisation and HAI on admission.

CONCLUSION

These data indicate that there is an epidemic spread of CRE in Vietnamese hospitals with rapid transmission to hospitalised patients.

Correlation between the use of antibiotics and development of a resistant bacterial infection in patients in the ICU

The current study analyzed the correlation between the use of antibiotics and development of a resistant bacterial infection in 454 patients in intensive care units (ICUs), and this study also examined factors related to development of an infection in order to facilitate more rational use of antibiotics and to reduce the incidence of resistant bacterial infections. Potential subjects were patients who were admitted to the ICU in 2016, and 454 such patients were selected using cluster sampling. Patient information was documented using an original questionnaire, Patients in the ICU with a Resistant Bacterial Infection. The correlation between use of an antibiotic and development of a resistant bacterial infection was examined. The rate of infection significantly increased over time and with receipt of various antibiotics. The development of a resistant bacterial infection was found to correlate with the use of antibiotics. Antibiotics should be used more carefully to reduce the incidence of resistant bacterial infections.

Prevalence and Risk Factors of Carbapenem-resistant Enterobacteriaceae Acquisition in an Emergency Intensive Care Unit in a Tertiary Hospital in Korea: a Case-Control Study

BACKGROUND

Infections caused by carbapenem-resistant Enterobacteriaceae (CRE) are associated with high mortality rates and their treatment is difficult because treatment is limited to certain antibiotics, such as colistin and tigecycline. We aimed to perform active surveillance culture of CRE (ASC-CRE) to monitor the prevalence of CRE acquisition during intensive care unit (ICU) care and to examine the potential risk factors associated with CRE acquisition.

METHODS

We conducted ASC-CRE on patients who were admitted to the ICU in the emergency room at a tertiary hospital. Rectal swabs were analyzed using methods established by the Centers for Disease Control and Prevention. To detect carbapenemase-producing CRE, a polymerase chain reaction assay to detect five carbapenemase genes (bla_NDM, bla_KPC, bla_VIM, bla_IMP-1, and bla_OXA-48) was performed.

RESULTS

There were 22 CRE acquisition in 21 patients (2.6%, 21/810) and the incidence of CRE acquisition was 4.3/1,000 person-days, respectively. The most common species detected was Klebsiella pneumoniae (72.7%, 16/22), and 9 carbapenemase-producing CREs (7 bla_KPC and 2 bla_NDM) were detected. Independent risk factors associated with CRE acquisition were men gender (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 1.3-21.3), history of admission within one year (aOR, 3.9; 95% CI, 1.2-12.1), co-colonization with multidrug-resistant Acinetobacter baumannii (aOR, 15.6; 95% CI, 3.6-67.8) and extended-spectrum β-lactamases-producing bacteria (aOR, 4.7; 95% CI, 1.5-14.6), and exposure to glycopeptide antibiotics (aOR, 3.6; 95% CI, 1.3-9.9).

CONCLUSION

The identification of patients with risk factors for CRE acquisition and early detection of CRE acquisition using ASC-CRE may be useful for CRE control.

Management of carbapenem-resistant Enterobacteriaceae infections

BACKGROUND

Carbapenem resistance is defined as in vitro non-susceptibility to any carbapenem and/or documented production of a carbapenemase. This feature has rapidly spread worldwide among clinical isolates of Enterobacteriaceae, mostly Klebsiella spp., and is associated with diverse molecular mechanisms. Carbapenem resistance is often associated with resistance to all traditional β-lactams and other classes of antibiotics, denoting a typical example of an extensively drug-resistant phenotype.

OBJECTIVES

To summarize and interpret in a balanced manner the most clinically relevant data in terms of carbapenem-resistant Enterobacteriaceae (CRE) infection management.

SOURCES

Data were extracted by PubMed and clinicaltrials.gov search and manual scrutiny among references of analysed articles.

CONTENT

Features of newer and older, rediscovered antimicrobial options for CRE are described. Observational studies and randomized clinical trials (RCT) of CRE treatment are summarized, with a specific focus on the effects of monotherapy compared with combination treatment.

IMPLICATIONS

The available evidence on the current management of CRE mostly comes from observational, non-comparative, retrospective, small studies, with a high risk of selection bias. Very little evidence comes from RCT. Conflicting results of RCT and observational studies call for caution before combination therapies are deemed superior to monotherapy. Data on newer agents have spurred enthusiasm but remain limited as concerns severe CRE infections. A balanced approach should guide the clinician in the choice of old or new drugs, and of monotherapies or combination regimens. Efforts should be made to perform adequately sized clinical trials answering well-defined research questions.

Epidemiology of carbapenem-resistant Enterobacteriaceae in a Tertiary Care Center in the Kingdom of Bahrain

PURPOSE

The purpose of the study is to estimate the rate of infection with carbapenem-resistant Enterobacteriaceae (CRE) in the main governmental tertiary care hospital in Bahrain.

MATERIALS AND METHODS

All clinical samples with positive growth of CRE over 6-year period (January 2012-December 2017) were collected from the microbiology laboratory data.

RESULTS

The CRE incidence was high in the first half of study period (2012-2014) and then decreased between 2015 and 2017, after implementation of intensified CRE control measure bundle. About 49.4% of CRE-positive samples were isolated from the elderly age group (above 65 years old), most of them were admitted in the intensive care unit (ICU). The most common isolated organisms were Klebsiella pneumoniae (87.0%), followed by Escherichia coli (7.9%). Isolates from deep tracheal aspirate and midstream urine specimens were the most common source of CRE isolates (27.3%) and (26.3%), respectively. Bacteremia was documented in 21.2% of cases. CRE isolates in the study showed high rates of resistance to aminoglycosides (72.2% resistant to amikacin and 67.3% to gentamicin). Alternatively, most isolates retained their susceptibility to colistin and tigecycline with sensitivity of 83.9% and 85.7%, respectively. Combined resistance to both colistin and tigecycline was observed in 0.06% of total isolates.

CONCLUSION

Elderly population and ICU admission were important risk factors for CRE acquisition. Most of CRE isolates were sensitive to both colistin and tigecycline, which make them the best combination for empiric frontline therapy for suspected serious CRE infection in our facility. Implementing CRE-bundled infection control measures significantly reduced the incidence of CRE infection in our hospital.

Control of Carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa in Healthcare Facilities: A Systematic Review and Reanalysis of Quasi-experimental Studies

Carbapenem-resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) are a serious cause of healthcare-associated infections, although the evidence for their control remains uncertain. We conducted a systematic review and reanalysis to assess infection prevention and control (IPC) interventions on CRE-CRAB-CRPsA in inpatient healthcare facilities to inform World Health Organization guidelines. Six major databases and conference abstracts were searched. Before-and-after studies were reanalyzed as interrupted time series if possible. Effective practice and organization of care (EPOC) quality criteria were used. Seventy-six studies were identified, of which 17 (22%) were EPOC-compatible and interrupted time series analyses, assessing CRE (n = 11; 65%), CRAB (n = 5; 29%) and CRPsA (n = 3; 18%). IPC measures were often implemented using a multimodal approach (CRE: 10/11; CRAB: 4/5; CRPsA: 3/3). Among all CRE-CRAB-CRPsA EPOC studies, the most frequent intervention components included contact precautions (90%), active surveillance cultures (80%), monitoring, audit and feedback of measures (80%), patient isolation or cohorting (70%), hand hygiene (50%), and environmental cleaning (40%); nearly all studies with these interventions reported a significant reduction in slope and/or level. The quality of EPOC studies was very low to low.

Risk Assessment After a Severe Hospital-Acquired Infection Associated With Carbapenemase-Producing Pseudomonas aeruginosa

IMPORTANCE

Resistance of gram-negative bacilli to carbapenems is rapidly emerging worldwide. In 2016, the World Health Organization defined the hospital-built environment as a core component of infection prevention and control programs. The hospital-built environment has recently been reported as a source for outbreaks and sporadic transmission events of carbapenemase-producing gram-negative bacilli from the environment to patients.

OBJECTIVE

To assess risk after the identification of an unexpected, severe, and lethal hospital-acquired infection caused by carbapenemase-producing Pseudomonas aeruginosa in a carbapenemase-low endemic setting.

DESIGN, SETTINGS, AND PARTICIPANTS

A case series study in which a risk assessment was performed on all 11 patients admitted to the combined cardiothoracic surgery and pulmonary diseases ward and the hospital-built environment in the Radboud University Medical Center, the Netherlands, in February 2018.

EXPOSURES

Water and aerosols containing carbapenemase-producing (Verona integron-mediated metallo-β-lactamase [VIM]) P aeruginosa.

MAIN OUTCOMES AND MEASURES

Colonization and/or infection of patients and/or contamination of the environment after the detection of 1 patient infected with carbapenemase-producing (VIM) P aeruginosa.

RESULTS

A total of 5 men (age range, 60-84 years) and 6 women (age range, 55-74 years) were admitted to the combined cardiothoracic surgery and pulmonary diseases ward. The risk assessment was performed after carbapenemase-producing (VIM) P aeruginosa was unexpectedly detected in a man in his early 60s, who had undergone a left-sided pneumonectomy and adjuvant radiotherapy. No additional cases (colonization or infection) of carbapenemase-producing (VIM) P aeruginosa were detected. Plausible transmission of carbapenemase-producing P aeruginosa from the hospital environment to the patient via the air was confirmed by whole-genome sequencing, which proved the relation of Pseudomonas strains from the patient, the shower drains in 8 patient rooms, 1 sink, and an air sample.

CONCLUSIONS AND RELEVANCE

This study suggests that rethinking the hospital-built environment, including shower drains and the sewage system, will be crucial for the prevention of severe and potential lethal hospital-acquired infections.

The clinical significance of carbapenem-resistant Klebsiella pneumoniae rectal colonization in critically ill patients: from colonization to bloodstream infection

PURPOSE

To highlight the clinical significance of carbapenem-resistant Klebsiella pneumoniae (CRKP) rectal colonization by examining the risk factors for CRKP rectal colonization and subsequent bloodstream infection (BSI) in critically ill patients.

METHODOLOGY

Prospective study of CRKP rectal colonization in an intensive care unit (ICU) during a 39-month period. CRKP strains isolated from both the blood cultures and corresponding rectal specimens (n=96) of patients were screened by PCR for the presence of antibiotic resistance-associated genes. Molecular analyses were conducted to investigate the clonal relatedness of CRKP strains from the rectal and blood specimens.

RESULTS

Among the 498 patients, 226 were rectally colonized by CRKP, 48 of whom developed a CRKP BSI. The median time from hospital admission to the detection of CRKP rectal colonization was 8 days, while the median time from colonization to BSI was 4 days. The duration of ICU stay, patient/nurse ratio and prior use of antianaerobic antimicrobials were associated with CRKP rectal colonization. No specific factor was associated with BSIs in the colonized patients. The blaKPC-2 gene was detected in all 96 strains, which were all classified as sequence type ST-258. Representative pairs (n=48) of CRKP strains colonizing and infecting the same patient shared the same pulsotype.

CONCLUSION

Our results indicate that hospitalized patients become infected with their colonizing strains, supporting the strong association between colonization and BSI. Limiting antianaerobic antimicrobial administration, reducing the duration of ICU stay and maintaining a low patient/nurse ratio are possible strategies to restrict rectal CRKP colonization in ICUs.

NDM Metallo-β-Lactamases and Their Bacterial Producers in Health Care Settings

New Delhi metallo-β-lactamase (NDM) is a metallo-β-lactamase able to hydrolyze almost all β-lactams. Twenty-four NDM variants have been identified in >60 species of 11 bacterial families, and several variants have enhanced carbapenemase activity. Klebsiella pneumoniae and Escherichia coli are the predominant carriers of bla _NDM, with certain sequence types (STs) (for K. pneumoniae, ST11, ST14, ST15, or ST147; for E. coli, ST167, ST410, or ST617) being the most prevalent. NDM-positive strains have been identified worldwide, with the highest prevalence in the Indian subcontinent, the Middle East, and the Balkans. Most bla _NDM-carrying plasmids belong to limited replicon types (IncX3, IncFII, or IncC). Commonly used phenotypic tests cannot specifically identify NDM. Lateral flow immunoassays specifically detect NDM, and molecular approaches remain the reference methods for detecting bla _NDM Polymyxins combined with other agents remain the mainstream options of antimicrobial treatment. Compounds able to inhibit NDM have been found, but none have been approved for clinical use. Outbreaks caused by NDM-positive strains have been reported worldwide, attributable to sources such as contaminated devices. Evidence-based guidelines on prevention and control of carbapenem-resistant Gram-negative bacteria are available, although none are specific for NDM-positive strains. NDM will remain a severe challenge in health care settings, and more studies on appropriate countermeasures are required.

Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study

Objective

To determine whether infection-prevention and control (IPC) interventions can reduce the colonisation and infection of intensive care unit (ICU)-acquired carbapenem-resistant Klebsiella pneumoniae (CRKP) in a general ICU ward in China.

Methods

We used a quasi-experimental before-and-after study design. The study was conducted in 4 stages: baseline period, January 2013-June 2013; IPC interventions period including de-escalation and targeted bundle interventions, July 2013-June 2014; modified IPC interventions period, July 2014-June 2015; and follow-up period, July 2015-June 2016. We used modified de-escalation interventions according to patient-risk assessments to prevent the transmission of CRKP.

Results

A total of 629 patients were enrolled in study. The incidence of ICU-acquired CRKP colonisation/infection was 10.08 (4.43-16.43) per 1000 ICU patient-days during the baseline period, and significantly decreased early during the IPC interventions, but the colonisation/infections reappeared in April 2014. During the modified IPC intervention and follow-up periods, the incidence of ICU-acquired CRKP colonisations/infections reduced to 5.62 (0.69-6.34) and 2.84 (2.80-2.89), respectively, with ongoing admission of cases with previously acquired CRKP. The incidence of ICU-acquired CRKP catheter-related bloodstream infections decreased from 2.54 during the baseline period to 0.41 during the follow-up period. The incidence of ventilator-associated pneumonia and skin and soft tissue infections showed a downward trend from 2.84 to 0.41 and from 3.4 to 0.47, respectively, with slight fluctuations.

Conclusions

Comprehensive IPC interventions including de-escalation and targeted bundle interventions showed a significant reduction in ICU-acquired CRKP colonisations/infections, despite ongoing admission of patients colonised/infected with CRKP.

Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis

BACKGROUND

Infections due to antibiotic-resistant bacteria are threatening modern health care. However, estimating their incidence, complications, and attributable mortality is challenging. We aimed to estimate the burden of infections caused by antibiotic-resistant bacteria of public health concern in countries of the EU and European Economic Area (EEA) in 2015, measured in number of cases, attributable deaths, and disability-adjusted life-years (DALYs).

METHODS

We estimated the incidence of infections with 16 antibiotic resistance-bacterium combinations from European Antimicrobial Resistance Surveillance Network (EARS-Net) 2015 data that was country-corrected for population coverage. We multiplied the number of bloodstream infections (BSIs) by a conversion factor derived from the European Centre for Disease Prevention and Control point prevalence survey of health-care-associated infections in European acute care hospitals in 2011-12 to estimate the number of non-BSIs. We developed disease outcome models for five types of infection on the basis of systematic reviews of the literature.

FINDINGS

From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 (95% uncertainty interval [UI] 583 148-763 966) infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. These infections accounted for an estimated 33 110 (28 480-38 430) attributable deaths and 874 541 (768 837-989 068) DALYs. The burden for the EU and EEA was highest in infants (aged <1 year) and people aged 65 years or older, had increased since 2007, and was highest in Italy and Greece.

INTERPRETATION

Our results present the health burden of five types of infection with antibiotic-resistant bacteria expressed, for the first time, in DALYs. The estimated burden of infections with antibiotic-resistant bacteria in the EU and EEA is substantial compared with that of other infectious diseases, and has increased since 2007. Our burden estimates provide useful information for public health decision-makers prioritising interventions for infectious diseases.

FUNDING

European Centre for Disease Prevention and Control.

Association between excreta management and incidence of extended-spectrum β-lactamase-producing Enterobacteriaceae: role of healthcare workers' knowledge and practices

BACKGROUND

The spread of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) in healthcare environments has become a major public health threat in recent years.

AIM

To assess how healthcare workers (HCWs) manage excreta and the possible association with the incidence of ESBL-PE.

METHODS

Eight hundred HCWs and 74 nurse-supervisors were questioned through two self-report questionnaires in order to assess their knowledge and practices, and to determine the equipment utilized for excreta management in 74 healthcare departments. Performance on equipment utilized, knowledge and practices were scored as good (score of 1), intermediate (score of 2) or poor (score of 3) on the basis of pre-established thresholds. Linear regression was performed to evaluate the association between HCWs' knowledge/practices and the incidence of ESBL-PE.

FINDINGS

Six hundred and eighty-eight HCWs (86%) and all nurse-supervisors participated in the survey. The proportions of respondents scoring 1, 2 and 3 were: 14.8%, 71.6% and 17.6% for equipment; 30.1%, 40.6 % and 29.3% for knowledge; and 2.0%, 71.9% and 26.1% for practices, respectively. The single regression mathematic model highlighted that poor practices (score of 3) among HCWs was significantly associated with increased incidence of ESBL-PE (P = 0.002).

CONCLUSIONS

A positive correlation was found between HCWs' practices for managing excreta and the incidence of ESBL-PE, especially in surgical units. There is an urgent need for development of public health efforts to enhance knowledge and practices of HCWs to better control the spread of multi-drug-resistant bacteria, and these should be integrated within infection control programmes.

Characteristics of NDM-1-producing Klebsiella pneumoniae ST234 and ST1412 isolates spread in a neonatal unit

BACKGROUND

The emergence of carbapenem-resistant Klebsiella pneumoniae (CR-KP) has become a significant problem worldwide and also being a major threat to children and newborns. Here we report an outbreak of NDM-1-producing K. pneumoniae in a neonatal unit.

RESULTS

Six CR-KP strains, isolated from neonates with symptoms of infection, were identified using a VITEK-2 compact system, and the clinical data were retrieved from the electronic case records. In vitro susceptibility testing with broth dilution method showed that all six K. pneumoniae isolates were resistant to carbapenems and susceptible to colistin, aminoglycosides, fluoroquinolones and tigecycline. Based on the polymerase chain reaction results, each isolate was found to be blaNDM-1 gene positive. Clonal relationships were analysed using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) and showed that two different PFGE patterns were formed, which belonged to sequence types ST234 and ST1412. Plasmids carrying blaNDM-1 were successfully transferred from four of the six isolates to an Escherichia coli recipient through conjugative assays. S1-PFGE and Southern blot hybridization showed that four NDM-1-producing K. pneumoniae were clonal and carried blaNDM-1 on the same plasmid. The outbreak was effectively controlled by reducing the potential infection sources. All the patients were successfully treated and recovered after receiving an increased dose of carbapenems. Although the source of this outbreak was not clear, comprehensive measures were carried out and the outbreak was effectively controlled.

CONCLUSIONS

ST234 and ST1412 of NDM-1-producing Klebsiella pneumoniae are the resistant clone spread in the neonatal unit, comprehensive infection control measures and optimized carbapenem therapy played an important role in controlling this NDM-1-producing K. pneumoniae outbreak.

Successful control of the first OXA-48 and/or NDM carbapenemase-producing Klebsiella pneumoniae outbreak in Slovenia 2014-2016

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) occur only sporadically in Slovenia.

AIM

To describe the first Slovenian carbapenemase-producing (CP) Klebsiella pneumoniae and Escherichia coli outbreak which occurred at the tertiary teaching hospital University Medical Centre Ljubljana from October 2014 to April 2015.

METHODS

A CPE-positive case was defined as any patient infected or colonized with CPE. A strict definition of a contact patient was adopted. Measures to prevent cross-transmission included cohorting of all CPE carriers with strict contact precautions and assignment of dedicated healthcare workers, cohorting of all contact patients until obtaining the result of screening cultures, systematic rectal screening of contact patients, and tagging of all CPE-positive cases and their contacts. Educational campaigns on CPEs were implemented. Clinical specimens were processed using standard procedures. Pulsed-field gel electrophoresis (PFGE) was used to determine relatedness. Multi-locus sequence typing was performed on CP K. pneumoniae isolates that belonged to different pulsotypes.

FINDINGS

Before the outbreak was brought under control, 40 patients were colonized or infected with OXA-48 and/or New Delhi metallo-β-lactamase (NDM)-producing CPE; in 38 patients OXA-48 and/or NDM-producing K. pneumoniae was detected, in seven OXA-48 and/or NDM-producing E. coli was found together with K. pneumoniae, and in two patients only CP E. coli was isolated. The outbreak was oligoclonal with two major CP K. pneumoniae clusters belonging to ST437 and ST147 in epidemiologically linked patients.

CONCLUSION

Initial standard control measures failed to prevent the outbreak. Once the problem had been recognized, strict infection control measures and the education of healthcare workers contributed to the successful control of the outbreak.

The Infinity War: How to Cope with Carbapenem-resistant Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CRE) are now spread worldwide. In Korea, the number of CRE isolation is rapidly increasing, and impending endemicity is a concern. To cope well with CRE, thorough infection control, such as active surveillance, early detection, strict contact precaution, cleaning the environment, and antibiotic stewardship is very important. Therapeutic options include polymyxin, tigecycline, fosfomycin or the combination of them with carbapenem, which is currently the mainstay of treatment. In addition, various combination regimens with new carbapenemase inhibitors such as avibactam, vaborbactam, or relebactam, and other classes of antimicrobials such as plazomicin and siderophore cephalosporin are in the process of evaluation.

Predictive factors for multidrug-resistant gram-negative bacteria among hospitalised patients with complicated urinary tract infections

Background

Patients with complicated urinary tract infections (cUTIs) frequently receive broad-spectrum antibiotics. We aimed to determine the prevalence and predictive factors of multidrug-resistant gram-negative bacteria in patients with cUTI.

Methods

This is a multicenter, retrospective cohort study in south and eastern Europe, Turkey and Israel including consecutive patients with cUTIs hospitalised between January 2013 and December 2014. Multidrug-resistance was defined as non-susceptibility to at least one agent in three or more antimicrobial categories. A mixed-effects logistic regression model was used to determine predictive factors of multidrug-resistant gram-negative bacteria cUTI.

Results

From 948 patients and 1074 microbiological isolates, Escherichia coli was the most frequent microorganism (559/1074), showing a 14.5% multidrug-resistance rate. Klebsiella pneumoniae was second (168/1074) and exhibited the highest multidrug-resistance rate (54.2%), followed by Pseudomonas aeruginosa (97/1074) with a 38.1% multidrug-resistance rate. Predictors of multidrug-resistant gram-negative bacteria were male gender (odds ratio [OR], 1.66; 95% confidence interval [CI], 1.20–2.29), acquisition of cUTI in a medical care facility (OR, 2.59; 95%CI, 1.80–3.71), presence of indwelling urinary catheter (OR, 1.44; 95%CI, 0.99–2.10), having had urinary tract infection within the previous year (OR, 1.89; 95%CI, 1.28–2.79) and antibiotic treatment within the previous 30 days (OR, 1.68; 95%CI, 1.13–2.50).

Conclusions

The current high rate of multidrug-resistant gram-negative bacteria infections among hospitalised patients with cUTIs in the studied area is alarming. Our predictive model could be useful to avoid inappropriate antibiotic treatment and implement antibiotic stewardship policies that enhance the use of carbapenem-sparing regimens in patients at low risk of multidrug-resistance.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0401-6) contains supplementary material, which is available to authorized users.

A survey on practices for active surveillance of carriage of multidrug-resistant bacteria in hospitals in the Autonomous Community of Valencia, Spain

A questionnaire-based cross-sectional study was conducted to gather information on current microbiological practices for active surveillance of carriage of multidrug-resistant (MDR) bacteria in hospitals from 14 health departments of the Autonomous Community of Valencia (ACV), Spain, which together provided medical attention to 3,271,077 inhabitants in 2017, approximately 70% of the population of the ACV. The survey consisted of 35 questions on MDR bacteria screening policies, surveillance approach chosen (universal vs. targeted), and microbiological methods and processes in use for routine detection and reporting of colonization by MDR bacteria, including the anatomical sites scheduled to be sampled for each MDR bacterial species, and the methodology employed (culture-based, molecular-based, or both). Our study revealed striking differences across centers, likely attributable to the lack of consensus on optimal protocols for sampling, body sites for screening, and microbiological testing, thus underscoring the need for consensus guidelines on these issues.

Wagenlehner F, Zimmer KP, Chakraborty T. Treatment Options for Carbapenem- Resistant Gram-Negative Infections

BACKGROUND

Rates of colonization and infection with carbapenem-resistant Gram-negative pathogens are on the rise, particularly in southeastern European countries, and this is increasingly true in Germany as well. The organisms in question include enterobacteriaceae such as Klebsiella pneumoniae and Escherichia coli and non-fermenting bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii. As the carbapenems have been the gold standard to date for the systemic treatment of serious infections with Gram-negative bacteria, carbapenem resistance presents new and difficult challenges in therapeutic decision-making, particularly because of the high frequency of coresistance.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and on other applicable literature.

RESULTS

Multiresistant Gram-negative (MRGN) pathogens are classified in Germany according to their resistance to four different classes of antibiotics; fluoroquinolones, piperacillin, third-generation cephalosporins, and carbapenems. Quadruple MRGN pathogens are resistant to all four groups, triple MRGN pathogens to three of them. There are a number of therapeutic alternatives to carbapenems that can be applied with the aid of sensitive microbiological and/or molecular genetic testing. The following antibiotics are often the only ones that can be used to treat quadruple MRGN pathogens: colistin, aminoglycosides, tigecycline, fosfomycin, ceftazidime/avibactam, and ceftolozan/tazobactam. Carbapenems, too, may still be an option in certain situations. There is also evidence that combinations of antibiotics against which the pathogen is resistant individually can some- times be a valid treatment option; these include combinations of colistin with one or two carbapenems.

CONCLUSION

The treatment of severe infection with carbapenem-resistant pathogens should be individualized and carried out in an interdisciplinary framework, in consideration of antibiotic pharmacokinetics and pharmacodynamics in each case. The treat- ment options are based on evidence from in vitro studies, retrospective studies, and case series, which must be interpreted with caution. Randomized clinical trials are needed to test each of the various combined approaches.

Impact of active surveillance and infection control measures on carbapenem-resistant Gram-negative bacterial colonization and infections in intensive care

BACKGROUND

Carbapenem-resistant Gram-negative bacteria (CRGNB) infections constitute a global threat for critically ill patients and the outcome of their hospitalization. Early identification of CRGNB through rectal surveillance cultures and routine infection control measures including contact precautions, use of appropriate disinfectants, staff education on cleaning, and hand hygiene may reduce the dissemination of CRGNB.

AIM

To assess the impact of enhanced infection control measures on CRGNB infections in a nine-bed polyvalent intensive care unit in a tertiary level hospital in an endemic area.

METHODS

A quasi-experimental study, which included patients with CRGNB infection retrospectively for six months and those participating in an active surveillance programme prospectively for the subsequent 22 months. Active surveillance programme (weekly rectal swabs) was implemented including two sub-periods with infection control measures and enhanced infection control measures. CRGNB incidence, prevalence, colonization pressure, infections and compliance with infection control measures and enhanced infection control measures were recorded. Analysis was performed through time-series and interrupted time-series.

FINDINGS

During the active surveillance programme, enhanced infection control measures led to a steeper downwards trend in incidence, prevalence, and colonization pressure for CRGNB compared to the infection control measures sub-period. The linear trend was for carbapenem-resistant Klebsiella pneumoniae (CRKP) and Pseudomonas aeruginosa (CRPA) infections to decrease from 19.6 to 8.1 infections per 1000 bed-days (IBD) (P = 0.001) and from 5.1 to 1.79 IBD (P = 0.043), respectively. By contrast, carbapenem-resistant Acinetobacter baumannii infections increased from 5.2 to 15.3 IBD (P = 0.001).

CONCLUSION

Enhanced infection control measures including enhanced hand hygiene, active surveillance combined with contact precautions, education, audits and feedback policies and interventions could reduce CRKP and CRPA in endemic areas.

An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England

BACKGROUND

Following hospital outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), Public Health England published a toolkit in December 2013 to promote the early detection, management, and control of CPE colonization and infection in acute hospital settings.

AIM

To examine awareness, uptake, implementation and usefulness of the CPE toolkit and identify potential barriers and facilitators to its adoption in order to inform future guidance.

METHODS

A cross-sectional survey of National Health Service (NHS) acute trusts was conducted in May 2016. Descriptive analysis and multivariable regression models were conducted, and narrative responses were analysed thematically and informed using behaviour change theory.

FINDINGS

Most (92%) acute trusts had a written CPE plan. Fewer (75%) reported consistent compliance with screening and isolation of CPE risk patients. Lower prioritization and weaker senior management support for CPE prevention were associated with poorer compliance. Awareness of the CPE toolkit was high and all trusts with patients infected or colonized with CPE had used the toolkit either as provided (32%), or to inform (65%) their own local CPE plan. Despite this, many respondents (80%) did not believe that the CPE toolkit guidance offered an effective means to prevent CPE or was practical to follow.

CONCLUSION

CPE prevention and control requires robust IPC measures. Successful implementation can be hindered by a complex set of factors related to their practical execution, insufficient resources and a lack of confidence in the effectiveness of the guidance. Future CPE guidance would benefit from substantive user involvement, processes for ongoing feedback, and regular guidance updates.

Controlling infectious disease outbreaks in low-income and middle-income countries

When an infectious disease outbreak is detected or suspected, a healthcare facility's infection control personnel should be notified and an outbreak control team formed that is pertinent to the size and severity of the outbreak and healthcare facility. Management of an infectious disease outbreak in a middle- or low-income country is challenging. Cost-effective recommendations that are easy to carry out and that have been stratified according to the type of infection and prevention and control intervention used are provided in this paper and constitute basic practices.

Defining Multidrug Resistance of Gram-Negative Bacteria in the Dutch-German Border Region-Impact of National Guidelines

Preventing the spread of multidrug-resistant Gram-negative bacteria (MDRGNB) is a public health priority. However, the definition of MDRGNB applied for planning infection prevention measures such as barrier precautions differs depending on national guidelines. This is particularly relevant in the Dutch–German border region, where patients are transferred between healthcare facilities located in the two different countries, because clinicians and infection control personnel must understand antibiograms indicating MDRGNB from both sides of the border and using both national guidelines. This retrospective study aimed to compare antibiograms of Gram-negative bacteria and classify them using the Dutch and German national standards for MDRGNB definition. A total of 31,787 antibiograms from six Dutch and four German hospitals were classified. Overall, 73.7% were no MDRGNB according to both guidelines. According to the Dutch and German guideline, 7772/31,787 (24.5%) and 4586/31,787 (12.9%) were MDRGNB, respectively (p < 0.0001). Major divergent classifications were observed for extended-spectrum β-lactamase (ESBL) -producing Enterobacteriaceae, non-carbapenemase-producing carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa and Stenotrophomonas maltophilia. The observed differences show that medical staff must carefully check previous diagnostic findings when patients are transferred across the Dutch–German border, as it cannot be assumed that MDRGNB requiring special hygiene precautions are marked in the transferred antibiograms in accordance with both national guidelines.