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Goodman KE, Taneja M, Magder LS, Klein EY, Sutherland M, Sorongon S, Tamma PD, Resnik P, Harris AD. A multi-center validation of the electronic health record admission source and discharge location fields against the clinical notes for identifying inpatients with long-term care facility exposure. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38634555 DOI: 10.1017/ice.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Identifying long-term care facility (LTCF)-exposed inpatients is important for infection control research and practice, but ascertaining LTCF exposure is challenging. Across a large validation study, electronic health record data fields identified 76% of LTCF-exposed patients compared to manual chart review. OBJECTIVE Residence or recent stay in a long-term care facility (LTCF) is an important risk factor for antibiotic-resistant bacterial colonization. However, absent dedicated intake questionnaires or resource-intensive chart review, ascertaining LTCF exposure in inpatients is challenging. We aimed to validate the electronic health record (EHR) admission and discharge location fields against the clinical notes for identifying LTCF-exposed inpatients. METHODS We conducted a retrospective study of 1020 randomly sampled adult admissions between 2016 and 2021 across 12 University of Maryland Medical System hospitals. Using study-developed guidelines, we categorized the following data for LTCF exposure: each admission’s history & physical (H&P) note, each admission’s EHR-extracted “Admission Source,” and (3) the EHR-extracted admission and discharge locations for previous admissions (≤90 days). We estimated sensitivities, with 95% CIs, of H&P notes and of EHR admission/discharge location fields for detecting “current” and “any recent” (≤90 days, including current) LTCF exposure. RESULTS For detecting current LTCF exposure, the sensitivity of the index admission’s EHR-extracted “Admission Source” was 46% (95% CI: 35%–58%) and of the H&P note was 92% (83%–97%). For detecting any recent LTCF exposure, the sensitivity of “Admission Source” across the index and previous admissions was 32% (24%–41%), “Discharge Location” across previous admission(s) was 57% (47%–66%), and of the H&P note was 68% (59%–76%). The combined sensitivity of admission source and discharge location for detecting any recent LTCF exposure was 76% (67%–83%). CONCLUSIONS The EHR-obtained admission source and discharge location fields identified 76% of LTCF-exposed patients compared to chart review but disproportionately missed currently exposed patients.
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Affiliation(s)
- Katherine E Goodman
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Monica Taneja
- The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eili Y Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Sutherland
- Departments of Emergency Medicine and Internal Medicine, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Scott Sorongon
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philip Resnik
- Department of Linguistics and Institute for Advanced Computer Studies, The University of Maryland, College Park, College Park, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland Institute for Health Computing, Bethesda, MD, USA
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Zilberman-Itskovich S, Simhon D, Laniado S, Plotnikov G, Marchaim D. Prolonged stay at an acute-care hospital in Israel among older adults awaiting transfer to post-acute care: retrospective study on risk factors and consequences. Eur Geriatr Med 2023; 14:145-151. [PMID: 36417176 DOI: 10.1007/s41999-022-00717-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Older adults frequently experience deconditioning following acute illnesses and require discharge from acute-care facilities to post-acute care facilities, which are limited. Our study aimed to explore predictors and outcomes associated with elongated length of stay (LOS) among older adults awaiting discharge to skilled nursing facility (SNF). METHODS Retrospective cohort study was conducted at Shamir Medical Center, Israel, among adults (> 65 years) eligible for SNF. ROC curve analysis was used to determine prolonged LOS based on the risk to fall. Logistic and Cox regressions were used to analyze predictors and outcomes. RESULTS Among 659 older adults awaiting transfer to SNF, 127 patients (24% among survivors of the index hospitalization) had prolonged LOS (> 12 days). The median age of patients was 82 years and 51% were females. The independent predictors for prolonged LOS were lower Norton index, higher MUST score, and admission from home. Prolonged LOS was independently associated with hospital-acquired infections, device related infections, and acquisitions of multidrug-resistant organisms. CONCLUSION Prolonged LOS among older adults, awaiting transfer to SNF, should be suspected among non-institutionalized older adults with lower nutritional status and higher risk of pressure ulcers. The burden associated with establishing additional SNF beds, must be outweighed vs. the substantial infectious complications among awaiting older adults.
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Affiliation(s)
- Shani Zilberman-Itskovich
- Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel. .,Department of Medicine I, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906, Tel-Aviv, Israel.
| | | | | | - Galina Plotnikov
- Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dror Marchaim
- Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Panlilio H, Neel A, Heydarian N, Best W, Atkins I, Boris A, Bui M, Dick C, Ferrell M, Gu T, Haight T, Roedl CC, Rice CV. Antibiofilm Activity of PEGylated Branched Polyethylenimine. ACS OMEGA 2022; 7:44825-44835. [PMID: 36530285 PMCID: PMC9753512 DOI: 10.1021/acsomega.2c04911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
Biofilm formation is an adaptive resistance mechanism that pathogens employ to survive in the presence of antimicrobials. Pseudomonas aeruginosa is an infectious Gram-negative bacterium whose biofilm allows it to withstand antimicrobial attack and threaten human health. Chronic wound healing is often impeded by P. aeruginosa infections and the associated biofilms. Previous findings demonstrate that 600 Da branched polyethylenimine (BPEI) can restore β-lactam potency against P. aeruginosa and disrupt its biofilms. Toxicity concerns of 600 Da BPEI are mitigated by covalent linkage with low-molecular-weight polyethylene glycol (PEG), and, in this study, PEGylated BPEI (PEG350-BPEI) was found exhibit superior antibiofilm activity against P. aeruginosa. The antibiofilm activity of both 600 Da BPEI and its PEG derivative was characterized with fluorescence studies and microscopy imaging. We also describe a variation of the colony biofilm model that was employed to evaluate the biofilm disruption activity of BPEI and PEG-BPEI.
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Affiliation(s)
- Hannah Panlilio
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Andrew Neel
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Neda Heydarian
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - William Best
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Isaac Atkins
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Andrew Boris
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Maggie Bui
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Catherine Dick
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Maya Ferrell
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Tingting Gu
- Department
of Biology, University of Oklahoma, 730 Van Vleet Oval, Room 314, Norman, Oklahoma 73019, United States
| | - Tristan Haight
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Chase C. Roedl
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Charles V. Rice
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
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Epidemiology and molecular characterization of fecal carriage of third-generation cephalosporin-resistant enterobacterales among elderly residents in Japan. J Infect Chemother 2022; 28:569-575. [PMID: 35039227 DOI: 10.1016/j.jiac.2021.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The spread of third-generation cephalosporin-resistant Gram-negative bacteria is a serious concern in acute and post-acute care settings. This study aimed to understand the epidemiology and molecular background of fecal colonization of resistant Enterobacterales in elderly people. METHODS In December 2015-December 2017, stool or rectal swab samples were collected from 101 elderly patients receiving home care, using long-term care facilities (LTCF), and living in nursing homes repeatedly at 3-9-month intervals. Patient clinical background data were collected from medical records. After phenotypic screening for extended-spectrum β-lactamase (ESBL), AmpC-type β-lactamase or carbapenemase production, drug resistance genes of isolates were analyzed using polymerase chain reaction (PCR). ESBL-producing Escherichia coli isolates obtained from the same patients in repetitive screenings were analyzed using PCR-based ORF typing. Risk factors for persistent carriage of resistant Enterobacterales were analyzed using multivariate analysis. RESULTS Resistant Enterobacterales isolates were detected in 37 of 101 (36.6%) and 29 of 80 (36.3%) residents in first and second screenings, respectively. ESBL-producing E. coli accounted for 80% isolates, the most common being CTX-M-9-group β-lactamase producers. Molecular epidemiological analysis revealed probable transmissions of ESBL-producing E. coli; 58% of ESBL-producing E. coli colonizers were persistent colonizers at least after 3 -month intervals. Age > 87 years and LTCF residence were independent risk factors for persistent carriage of ESBL-producing E. coli. CONCLUSIONS We showed, for the first time, high persistent colonization rate of ESBL-producing E. coli among elderly people in post-acute care settings with probable horizontal transmission. We also identified significant risk factors for persistent colonization.
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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6
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Moschou A, Ioannou P, Moraitaki E, Stafylaki D, Maraki S, Samonis G, Kofteridis DP. Rectal Colonization by Drug Resistant Bacteria in Nursing Home Residents in Crete, Greece. Trop Med Infect Dis 2021; 6:tropicalmed6030123. [PMID: 34287352 PMCID: PMC8293340 DOI: 10.3390/tropicalmed6030123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/03/2021] [Accepted: 07/03/2021] [Indexed: 11/30/2022] Open
Abstract
(1) Background: In an area with a high prevalence of multi-drug resistant Gram-negative bacteria (MDR-GNB), we investigated the colonization of nursing home residents by such organisms. (2) Methods: A point prevalence study was performed in six nursing homes of the Heraklion area on the island of Crete. A rectal swab was taken and cultured from each participant, while additional risk factors such as recent hospitalization or antimicrobial usage were recorded and evaluated. (3) Results: A total of 137 nursing home residents were included in the study. Their mean age was 82.1 years and 19.7% were males. In total, cultures yielded 255 GNB; E. coli, K. pneumoniae and P. aeruginosa were the most common. Among the microorganisms cultured, 17.6% had the extended-spectrum beta-lactamase phenotype, while 18% were MDR. A statistically significant association was found between recent antimicrobial use and colonization by MDR-GNB; (4) Conclusions: Colonization by MDR-GNB was found to be highly prevalent in nursing home residents. Recent antimicrobial use was associated with MDR-GNB carriage.
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Affiliation(s)
- Aikaterini Moschou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, PC 71110 Crete, Greece; (A.M.); (G.S.); (D.P.K.)
| | - Petros Ioannou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, PC 71110 Crete, Greece; (A.M.); (G.S.); (D.P.K.)
- Correspondence: ; Tel.: +30-28-1039-2424
| | - Eleni Moraitaki
- Department of Clinical Microbiology, University Hospital of Heraklion, PC 71110 Crete, Greece; (E.M.); (D.S.); (S.M.)
| | - Dimitra Stafylaki
- Department of Clinical Microbiology, University Hospital of Heraklion, PC 71110 Crete, Greece; (E.M.); (D.S.); (S.M.)
| | - Sofia Maraki
- Department of Clinical Microbiology, University Hospital of Heraklion, PC 71110 Crete, Greece; (E.M.); (D.S.); (S.M.)
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, PC 71110 Crete, Greece; (A.M.); (G.S.); (D.P.K.)
| | - Diamantis P. Kofteridis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, PC 71110 Crete, Greece; (A.M.); (G.S.); (D.P.K.)
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Panlilio H, Lam AK, Heydarian N, Haight T, Wouters CL, Moen EL, Rice CV. Dual-Function Potentiation by PEG-BPEI Restores Activity of Carbapenems and Penicillins against Carbapenem-Resistant Enterobacteriaceae. ACS Infect Dis 2021; 7:1657-1665. [PMID: 33945257 PMCID: PMC8689638 DOI: 10.1021/acsinfecdis.0c00863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The rise of life-threatening carbapenem-resistant Enterobacteriaceae (CRE) infections has become a critical medical threat. Some of the most dangerous CRE bacteria can produce enzymes that degrade a wide range of antibiotics, including carbapenems and β-lactams. Infections by CRE have a high mortality rate, and survivors can have severe morbidity from treatment with toxic last-resort antibiotics. CRE have mobile genetic elements that transfer resistance genes to other species. These bacteria also circulate throughout the healthcare system. The mobility and spread of CRE need to be curtailed, but these goals are impeded by having few agents that target a limited range of pathogenic CRE species. Against CRE possessing the metallo-β-lactamase NDM-1, Klebsiella pneumoniae ATCC BAA-2146 and Escherichia coli ATCC BAA-2452, the potentiation of meropenem and imipenem is possible with low-molecular weight branched polyethylenimine (600 Da BPEI) and its poly(ethylene glycol) (PEG)ylated derivative (PEG-BPEI) that has a low in vivo toxicity. The mechanism of action is elucidated with fluorescence assays of drug influx and isothermal calorimetry data showing the chelation of essential Zn2+ ions. These results suggested that 600 Da BPEI and PEG-BPEI may also improve the uptake of antibiotics and β-lactamase inhibitors. Indeed, the CRE E. coli strain is rendered susceptible to the combination of piperacillin and tazobactam. These results expand the possible utility of 600 Da BPEI potentiators, where previously we have demonstrated the ability to improve antibiotic efficacy against antibiotic resistant clinical isolates of Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis.
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Affiliation(s)
- Hannah Panlilio
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Anh K Lam
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Neda Heydarian
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Tristan Haight
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Cassandra L Wouters
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Erika L Moen
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Charles V Rice
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
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Aliyu S, McGowan K, Hussain D, Kanawati L, Ruiz M, Yohannes S. Prevalence and Outcomes of Multi-Drug Resistant Blood Stream Infections Among Nursing Home Residents Admitted to an Acute Care Hospital. J Intensive Care Med 2021; 37:565-571. [PMID: 33938320 DOI: 10.1177/08850666211014450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The prevalence of multi-drug resistant organism (MDRO) colonization in nursing home residents has been well documented, but little is known about the impact of MDRO bloodstream infections (BSIs). The aim of this study was to assess the prevalence, cost, and outcomes of MDRO-BSI vs. non-MDRO-BSI among nursing home residents. DESIGN Retrospective cohort study. SETTING 960 bed tertiary academic medical center. PATIENTS Persons ≥18 years old admitted to an acute care tertiary hospital from Skilled Nursing Facilities with a diagnosis of sepsis between 2015 and 2018. INTERVENTIONS Retrospective analysis of prevalence and outcomes. MEASUREMENTS AND MAIN RESULTS Among patients admitted to the study hospital with a diagnosis of sepsis during the study period, 7% were from nursing homes. The prevalence of MDRO-BSI was 47%. We identified 54 (50%) gram positive BSIs, 48 (45%) gram negative BSI and 5 (5%) fungal BSI. Thirty-one (57%) of the gram-positive infections and 14 (30%) of the gram-negative infections were with MDROs. The prevalence of BSI organisms were Staphylococcus aureus in 24%, Escherichia coli in 14%, Proteus mirabilis in 13%, Staphylococcus epidermidis in 8%, Enterococcus faecalis in 7%, and Klebsiella pneumoniae in 6%. We found that intensive care unit length of stay (7 days vs 5 days, P = .009), direct cost ($13,639 vs $9,922, P = .027), and total cost ($23,752 vs $17,900 P = .032) were significantly higher in patients with MDRO-BSI vs. non-MDRO-BSI. Patients with MDRO-BSI were twice as likely to receive inappropriate empiric antiinfective therapy (31% vs 16%, P = .006) and were more likely to die (49.1% vs 29.6%, P = .049). CONCLUSION Nursing home residents have a high prevalence of MDRO-BSI, which is associated with higher risk of receiving inappropriate initial anti-infective therapy, higher cost, higher ICU LOS, and higher mortality. Our research adds new information about the prevalence of fungemia in this population.
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Affiliation(s)
- Sainfer Aliyu
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Kevin McGowan
- Georgetown University School of Medicine, Washington, DC, USA
| | - Dilbi Hussain
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Lama Kanawati
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Maria Ruiz
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Seife Yohannes
- 8405MedStar Washington Hospital Center, Washington, DC, USA
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A "resistance calculator": Simple stewardship intervention for refining empiric practices of antimicrobials in acute-care hospitals. Infect Control Hosp Epidemiol 2021; 42:1082-1089. [PMID: 33736724 PMCID: PMC8459314 DOI: 10.1017/ice.2020.1372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: In the era of widespread resistance, there are 2 time points at which most empiric prescription errors occur among hospitalized adults: (1) upon admission (UA) when treating patients at risk of multidrug-resistant organisms (MDROs) and (2) during hospitalization, when treating patients at risk of extensively drug-resistant organisms (XDROs). These errors adversely influence patient outcomes and the hospital’s ecology. Design and setting: Retrospective cohort study, Shamir Medical Center, Israel, 2016. Patients: Adult patients (aged >18 years) hospitalized with sepsis. Methods: Logistic regressions were used to develop predictive models for (1) MDRO UA and (2) nosocomial XDRO. Their performances on the derivation data sets, and on 7 other validation data sets, were assessed using the area under the receiver operating characteristic curve (ROC AUC). Results: In total, 4,114 patients were included: 2,472 patients with sepsis UA and 1,642 with nosocomial sepsis. The MDRO UA score included 10 parameters, and with a cutoff of ≥22 points, it had an ROC AUC of 0.85. The nosocomial XDRO score included 7 parameters, and with a cutoff of ≥36 points, it had an ROC AUC of 0.87. The range of ROC AUCs for the validation data sets was 0.7–0.88 for the MDRO UA score and was 0.66–0.75 for nosocomial XDRO score. We created a free web calculator (https://assafharofe.azurewebsites.net). Conclusions: A simple electronic calculator could aid with empiric prescription during an encounter with a septic patient. Future implementation studies are needed to evaluate its utility in improving patient outcomes and in reducing overall resistances.
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Bartolo M, Zucchella C, Aabid H, Valoriani B, Mancuso M, Intiso D. Healthcare-Associated Infections in Subjects With Severe Acquired Brain Injury: The Effect of Microbial Colonization on the Functional Outcome. Data From a Multicenter Observational Study. Front Neurol 2020; 11:563275. [PMID: 33240197 PMCID: PMC7683713 DOI: 10.3389/fneur.2020.563275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Hospital-acquired infections (HAIs) and microbial colonization are a worldwide serious threat for human health. Neurological patients with infections who undergo rehabilitation have a significantly poor recovery. The effect of microbial colonization on the functional outcome in severe acquired brain injury (sABI) subjects is still unclear. Aim: The aim of this multicenter observational study was to describe the clinical impact of HAIs and colonization on the functional outcome of sABI subjects admitted to inpatient neurorehabilitation. Methods: Patients were assigned to three groups: infected (INF), not infected (noINF), and colonized (COL). The Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale, Disability Rating Scale, and modified Barthel Index (mBI) assessments were performed both at admission and discharge. Results: Two hundred sixty-five (92 female/173 male) patients were enrolled: 134 were assigned to INF, 63 to COL, and 68 to noINF. In the INF group, 231 culture specimens were found positive for bloodstream (44.2%), respiratory tract (25.5%), urinary tract (18.6%), gastrointestinal tract (8.3%), skin (3%), and cerebrospinal fluid (0.4%) infections. After rehabilitation, all groups showed a significant improvement in all assessment tests, except for the noINF group that did not show any improvement in GCS. Both noINF and COL groups showed a significantly higher gain in mBI than the INF group (p = 0.000). The COL group showed a significantly higher gain than the noINF group in GCS (p = 0.001). A significantly lower improvement was detected in the INF group than the COL and noINF groups. The rate of patients who needed functional isolation was higher in the INF group than the COL group. Length of stay (LOS) (in days) was 56 ± 50.7, 88.3 ± 55, and 101.3 ± 73.6 for noINF, INF, and COL groups, respectively. The number of deaths in the INF group was significantly higher (24.6%) than the noINF group (7.4%) (p = 0.005) and comparable to the COL group (19%). Conclusion: Colonized sABI patients obtained a similar functional outcome to that of subjects who had no infections, even if they needed a significantly higher LOS.
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Affiliation(s)
- Michelangelo Bartolo
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Bergamo, Italy
| | | | - Hend Aabid
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Bergamo, Italy
| | - Beatrice Valoriani
- Medicine Unit, Ospedali Riuniti della Valdichiana, Presidio di Nottola, Siena, Italy
| | - Mauro Mancuso
- Tuscany Rehabilitation Clinic, Arezzo, Italy.,Physical and Rehabilitative Medicine Unit, NHS-USL Toscana Sud Est, Grosseto, Italy
| | - Domenico Intiso
- Unit of Neurorehabilitation and Rehabilitation Medicine, Istituto di Ricovero e Cura a Carattere Scientifico "Casa Sollievo della Sofferenza, " Foggia, Italy
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11
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Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-Spectrum β-Lactamase Producing Enterbacterales Infections: An Update. Infect Dis Clin North Am 2020; 34:677-708. [PMID: 33011052 DOI: 10.1016/j.idc.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, that is, the most common human pathogens outside of the hospital setting. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This poses an enormous burden and threat to public health. This article aims to narrate the evolving epidemiology of ESBL infections and highlights current challenges in terms of management and prevention of these common infections.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 6423906 Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Division of Internal Medicine, Shaare Zedek Medical Center, 12 Shmuel Bait Street, Jerusalem 9103102, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.
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12
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Arena F, Di Pilato V, Vannetti F, Fabbri L, Antonelli A, Coppi M, Pupillo R, Macchi C, Rossolini GM. Population structure of KPC carbapenemase-producing Klebsiella pneumoniae in a long-term acute-care rehabilitation facility: identification of a new lineage of clonal group 101, associated with local hyperendemicity. Microb Genom 2020; 6:e000308. [PMID: 32003322 PMCID: PMC7067035 DOI: 10.1099/mgen.0.000308] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/27/2019] [Indexed: 01/15/2023] Open
Abstract
In this work, we used a whole-genome sequencing (WGS) approach to study the features of KPC-producing Klebsiella pneumoniae (KPC-Kp) spreading in a large Italian long-term acute-care rehabilitation facility (LTACRF), and to track the dynamics of dissemination within this setting. Thirty-eight, non-replicated, KPC-Kp isolates from colonized patients (either already colonized at admission or colonized during admission), collected during 2016, were subjected to antimicrobial-susceptibility testing and WGS. All isolates were resistant to β-lactams, with the exception of ceftazidime/avibactam (97.4 % susceptible). The second most effective agent was fosfomycin, followed by colistin, trimethoprim/sulfamethoxazole, gentamicin and amikacin (92.1, 86.8, 60.5, 44.7 and 50 % of susceptibility, respectively). A large proportion of isolates (n=18/38, 47.4%) belonged to clonal group (CG) 101, and most of them (n=15) to a new sequence type (ST) designated as ST2502. All the CG101 isolates had a capsule locus type KL17. The ST2502 harboured the genes encoding for the yersiniabactin siderophore and the ArmA methylase, conferring high-level resistance to aminoglycosides. The second most represented lineage of isolates (16/38, 42.1%) belonged to ST512 of CG258. Analysing WGS data, we were able to ascertain the common origin of some isolates imported from other hospitals, and to track several clusters of in-LTACRF cross-transmissions. The results revealed that, in peculiar epidemiological settings such as LTACRF, new KPC-Kp clones different from those prevailing in acute-care hospitals and associated with uncommon resistance and virulence determinants can successfully emerge and disseminate.
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Affiliation(s)
- Fabio Arena
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
- Present address: Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
- Present address: Don Carlo Gnocchi Foundation, Florence, Italy
| | - Vincenzo Di Pilato
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Present address: Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | | | | | - Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Coppi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
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Detection and Colonization of Multidrug Resistant Organisms in a Regional Teaching Hospital of Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071104. [PMID: 30925662 PMCID: PMC6479599 DOI: 10.3390/ijerph16071104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 12/20/2022]
Abstract
This study evaluated the prevalence of clinical multidrug-resistant organisms (MDROs) and analyzed correlations between MDROs and patient characteristics in a regional teaching hospital of Taiwan. A retrospective comparative case-control study was conducted from January 2016 to August 2018 by collecting data from 486 hospitalized and non-hospitalized patients (M = 286, F = 200), including patient gender and age, microbial species, and antibiotic susceptibility. The results indicated that at least one MDRO was isolated from 5.3–6.3% of patients (p < 0.05), with an average age of 61.08 years. Of the MDROs strains, vancomycin-resistant enterococcus and carbapenem-resistant acinetobacter baumannii increased annually (p < 0.002 and p < 0.012, respectively). Three factors of age (over 60 years), treatment in an intensive care unit (ICU), and specimen category were statistically significant (p < 0.039, p < 0.001 and p < 0.001, respectively) and indicated that elderly patients in an ICU have a higher risk of being infected by MDROs. The outpatients infected by methicillin-resistant staphylococcus aureus (MRSA) were more frequent than inpatients, implying the existence of community-acquired MRSA strains. The results of this study could provide valuable information for the detection and colonization of multidrug-resistant organisms in hospital infection control systems.
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14
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Adams MD, Wright MS, Karichu JK, Venepally P, Fouts DE, Chan AP, Richter SS, Jacobs MR, Bonomo RA. Rapid Replacement of Acinetobacter baumannii Strains Accompanied by Changes in Lipooligosaccharide Loci and Resistance Gene Repertoire. mBio 2019; 10:e00356-19. [PMID: 30914511 PMCID: PMC6437055 DOI: 10.1128/mbio.00356-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/14/2022] Open
Abstract
The population structure of health care-associated pathogens reflects patterns of diversification, selection, and dispersal over time. Empirical data detailing the long-term population dynamics of nosocomial pathogens provide information about how pathogens adapt in the face of exposure to diverse antimicrobial agents and other host and environmental pressures and can inform infection control priorities. Extensive sequencing of clinical isolates from one hospital spanning a decade and a second hospital in the Cleveland, OH, metropolitan area over a 3-year time period provided high-resolution genomic analysis of the Acinetobacter baumannii metapopulation. Genomic analysis demonstrated an almost complete replacement of the predominant strain groups with a new, genetically distinct strain group during the study period. The new group, termed clade F, differs from other global clone 2 (GC2) strains of A. baumannii in several ways, including its antibiotic resistance and lipooligosaccharide biosynthesis genes. Clade F strains are part of a large phylogenetic group with broad geographic representation. Phylogenetic analysis of single-nucleotide variants in core genome regions showed that although the Cleveland strains are phylogenetically distinct from those isolated from other locations, extensive intermixing of strains from the two hospital systems was apparent, suggesting either substantial exchange of strains or a shared, but geographically restricted, external pool from which infectious isolates were drawn. These findings document the rapid evolution of A. baumannii strains in two hospitals, with replacement of the predominant clade by a new clade with altered lipooligosaccharide loci and resistance gene repertoires.IMPORTANCE Multidrug-resistant (MDR) A. baumannii is a difficult-to-treat health care-associated pathogen. Knowing the resistance genes present in isolates causing infection aids in empirical treatment selection. Furthermore, knowledge of the genetic background can assist in tracking patterns of transmission to limit the spread of infections in hospitals. The appearance of a new genetic background in A. baumannii strains with a different set of resistance genes and cell surface structures suggests that strong selective pressures exist, even in highly MDR pathogens. Because the new strains have levels of antimicrobial resistance similar to those of the strains that were displaced, we hypothesize that other features, including host colonization and infection, may confer additional selective advantages and contribute to their increased prevalence.
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Affiliation(s)
- Mark D Adams
- The J. Craig Venter Institute, La Jolla, California, USA
| | | | - James K Karichu
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Agnes P Chan
- The J. Craig Venter Institute, Rockville, Maryland, USA
| | - Sandra S Richter
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael R Jacobs
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University and CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
- Department of Pharmacology, Case Western Reserve University and CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
- Department of Molecular Biology and Microbiology, Case Western Reserve University and CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
- Department of Biochemistry, Case Western Reserve University and CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
- Center for Proteomics, Case Western Reserve University and CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
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15
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Wang M, Wei H, Zhao Y, Shang L, Di L, Lyu C, Liu J. Analysis of multidrug-resistant bacteria in 3223 patients with hospital-acquired infections (HAI) from a tertiary general hospital in China. Bosn J Basic Med Sci 2019; 19:86-93. [PMID: 30579325 DOI: 10.17305/bjbms.2018.3826] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/14/2018] [Indexed: 01/09/2023] Open
Abstract
The frequency of antimicrobial resistance has increased globally due to misuse and overuse of antibiotics, and multi-drug resistant (MDR) bacteria are now recognized as a major cause of hospital-acquired infections (HAI). Our aim was to investigate the prevalence, distribution, and antimicrobial susceptibility rates of MDR bacteria in patients with HAI from a tertiary hospital in China. We retrospectively evaluated all patients with a confirmed diagnosis of bacterial infection at a tertiary general hospital in Jining, for the period between January 2012 and December 2014. The following clinical and demographic data were collected: age, sex, specimens, treatment, microbiology results, and antibiotic resistance patterns of isolates. Bacterial identification and susceptibility testing were performed using VITEK 2 COMPACT system. We screened a total of 15,588 patients, out of which 7579 (48.6%) had an HAI. MDR showed 3223 out of 7579 isolates (42.5%). The most frequently isolated MDR bacteria in patients with HAI were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (n = 1216/3223, 37.7%), MDR Pseudomonas aeruginosa (n = 627/3223, 19.5%) and MDR Acinetobacter baumannii (n = 588/3223, 18.2%). MDR-HAI were more common in males (2074/3223, 64.4%) and in elderly patients (≥60 years; 1196/3223, 37.1%). Sputum was the main source of MDR isolates (2056/3223, 63.8%). Patients with MDR-HAI were predominantly distributed in different types of intensive care units. MDR strains in our study showed resistance to most current antibiotics. Overall, patients with HAI infections attributed to MDR bacteria were widely distributed in our hospital. Enhanced surveillance of MDR bacteria is critical for guiding the rational use of antibiotics and reducing the incidence of HAI.
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Affiliation(s)
- Meng Wang
- Department of Medical Affairs, Jining NO.1 People's Hospital, Jining, Shandong Province, China.
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16
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How to: molecular investigation of a hospital outbreak. Clin Microbiol Infect 2018; 25:688-695. [PMID: 30287413 DOI: 10.1016/j.cmi.2018.09.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studying hospital outbreaks by using molecular tools, i.e. synthesizing the molecular epidemiology data to its appropriate clinical-epidemiologic context, is crucial in order to identify infection source, infer transmission dynamics, appropriately allocate prevention resources and implement control measures. Whole-genome sequencing (WGS) of pathogens has become the reference standard, as it is becoming more accessible and affordable. Consequently, sequencing of the full pathogen genome via WGS and major progress in fit-for-purpose genomic data analysis tools and interpretation is revolutionizing the field of outbreak investigations in hospitals. Metagenomics is an additional evolving field that might become commonly used in the future for outbreak investigations. Nevertheless, practitioners are frequently limited in terms of WGS or metagenomics, especially for local outbreak analyses, as a result of costs or logistical considerations, reduced or lack of locally available resources and/or expertise. As a result, traditional approaches, including pulsed-field gel electrophoresis, repetitive-element palindromic PCR and multilocus sequence typing, along with other typing methods, are still widely used. AIMS To provide practitioners with evidenced-based action plans for usage of the various typing techniques in order to investigate the molecular epidemiology of nosocomial outbreaks, of clinically significant pathogens in acute-care hospitals. SOURCES PubMed search with relevant keywords along with personal collection of relevant publications. CONTENT Representative case scenarios and critical review of the relevant scientific literature. IMPLICATIONS The review provides practical action plans to manage molecular epidemiologic investigations of outbreaks caused by clinically significant nosocomial pathogens, while prioritizing the use and timely integration of the various methodologies.
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17
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Diversity of the epidemiology of carbapenemase-producing Enterobacteriaceae in long-term acute care rehabilitation settings from an area of hyperendemicity, and evaluation of an intervention bundle. J Hosp Infect 2018; 100:29-34. [DOI: 10.1016/j.jhin.2018.05.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/30/2018] [Indexed: 02/04/2023]
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18
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Seekatz AM, Bassis CM, Fogg L, Moore NM, Rhee Y, Lolans K, Weinstein RA, Lin MY, Young VB, Hayden MK. Gut Microbiota and Clinical Features Distinguish Colonization With Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae at the Time of Admission to a Long-term Acute Care Hospital. Open Forum Infect Dis 2018; 5:ofy190. [PMID: 30151415 PMCID: PMC6101546 DOI: 10.1093/ofid/ofy190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/27/2018] [Indexed: 12/29/2022] Open
Abstract
Background Identification of gut microbiota features associated with antibiotic-resistant bacterial colonization may reveal new infection prevention targets. Methods We conducted a matched, case–control study of long-term acute care hospital (LTACH) patients to identify gut microbiota and clinical features associated with colonization by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp), an urgent antibiotic resistance threat. Fecal or rectal swab specimens were collected and tested for KPC-Kp; 16S rRNA gene-based sequencing was performed. Comparisons were made between cases and controls in calibration and validation subsamples using microbiota similarity indices, logistic regression, and unit-weighted predictive models. Results Case (n = 32) and control (n = 99) patients had distinct fecal microbiota communities, but neither microbiota diversity nor inherent clustering into community types distinguished case and control specimens. Comparison of differentially abundant operational taxonomic units (OTUs) revealed 1 OTU associated with case status in both calibration (n = 51) and validation (n = 80) subsamples that matched the canonical KPC-Kp strain ST258. Permutation analysis using the presence or absence of OTUs and hierarchical logistic regression identified 2 OTUs (belonging to genus Desulfovibrio and family Ruminococcaceae) associated with KPC-Kp colonization. Among clinical variables, the presence of a decubitus ulcer alone was independently and consistently associated with case status. Combining the presence of the OTUs Desulfovibrio and Ruminococcaceae with decubitus ulcer increased the likelihood of KPC-Kp colonization to >38% in a unit-weighted predictive model. Conclusions We identified microbiota and clinical features that distinguished KPC-Kp gut colonization in LTACH patients, a population particularly susceptible to KPC-Kp infection. These features may warrant further investigation as markers of risk for KPC-Kp colonization.
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Affiliation(s)
- Anna M Seekatz
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Christine M Bassis
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Louis Fogg
- Department of Nursing, Rush College of Nursing, Chicago, Illinois
| | | | - Yoona Rhee
- Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College, Chicago, Illinois
| | | | - Robert A Weinstein
- Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College, Chicago, Illinois.,Cook County Health and Hospitals System, Chicago, Illinois
| | - Michael Y Lin
- Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College, Chicago, Illinois
| | - Vincent B Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mary K Hayden
- Department of Pathology.,Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College, Chicago, Illinois
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19
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Friedman ND, Levit D, Taleb E, Marcus G, Michaeli L, Broide M, Mengesha B, Zaidenstein R, Lazarovitch T, Dadon M, Kaye KS, Marchaim D. Towards a Definition for Health Care-Associated Infection. Open Forum Infect Dis 2018; 5:ofy116. [PMID: 29942821 PMCID: PMC6007215 DOI: 10.1093/ofid/ofy116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/22/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Health care-associated infection (HcAI) is a term frequently used to describe community-onset infections likely to be caused by multidrug-resistant organisms (MDROs). The most frequently used definition was developed at Duke University Medical Center in 2002 (Duke-2002). Although some professional societies have based management recommendations on Duke-2002 (or modifications thereof), neither Duke-2002 nor other variations have had their performance measured. METHODS A case-control study was conducted at Assaf Harofeh Medical Center (AHMC) of consecutive adult bloodstream infections (BSIs). A multivariable model was used to develop a prediction score for HcAI, measured by the presence of MDRO infection on admission. The performances of this new score and previously developed definitions at predicting MDRO infection on admission were measured. RESULTS Of the 504 BSI patients enrolled, 315 had a BSI on admission and 189 had a nosocomial BSI. Patients with MDRO-BSI on admission (n = 100) resembled patients with nosocomial infections (n = 189) in terms of epidemiological characteristics, illness acuity, and outcomes more than patients with non-MDRO-BSI on admission (n = 215). The performances of both the newly developed score and the Duke-2002 definition to predict MDRO infection on admission were suboptimal (area under the receiver operating characteric curve, 0.76 and 0.68, respectively). CONCLUSIONS Although the term HcAI is frequently used, its definition does not perform well at predicting MDRO infection present on admission to the hospital. A validated score that calculates the risk of MDRO infection on admission is still needed to guide daily practice and improve patient outcomes.
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Affiliation(s)
- N Deborah Friedman
- Departments of Medicine and Infectious Diseases, Barwon Health, Geelong, VIC, Australia
| | - Dana Levit
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Eyal Taleb
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Gil Marcus
- Department of Internal Medicine A, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Leah Michaeli
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Mor Broide
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Bethlehem Mengesha
- Department of Internal Medicine A, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Ronit Zaidenstein
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
- Department of Internal Medicine A, Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tsilia Lazarovitch
- Department of Clinical Microbiology Laboratory, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Mor Dadon
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dror Marchaim
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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20
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Toth DJA, Khader K, Slayton RB, Kallen AJ, Gundlapalli AV, O'Hagan JJ, Fiore AE, Rubin MA, Jernigan JA, Samore MH. The Potential for Interventions in a Long-term Acute Care Hospital to Reduce Transmission of Carbapenem-Resistant Enterobacteriaceae in Affiliated Healthcare Facilities. Clin Infect Dis 2018; 65:581-587. [PMID: 28472233 DOI: 10.1093/cid/cix370] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/18/2017] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) are high-priority bacterial pathogens targeted for efforts to decrease transmissions and infections in healthcare facilities. Some regions have experienced CRE outbreaks that were likely amplified by frequent transmission in long-term acute care hospitals (LTACHs). Planning and funding of intervention efforts focused on LTACHs is one proposed strategy to contain outbreaks; however, the potential regional benefits of such efforts are unclear. Methods We designed an agent-based simulation model of patients in a regional network of 10 healthcare facilities including 1 LTACH, 3 short-stay acute care hospitals (ACHs), and 6 nursing homes (NHs). The model was calibrated to achieve realistic patient flow and CRE transmission and detection rates. We then simulated the initiation of an entirely LTACH-focused intervention in a previously CRE-free region, including active surveillance for CRE carriers and enhanced isolation of identified carriers. Results When initiating the intervention at the first clinical CRE detection in the LTACH, cumulative CRE transmissions over 5 years across all 10 facilities were reduced by 79%-93% compared to no-intervention simulations. This result was robust to changing assumptions for transmission within non-LTACH facilities and flow of patients from the LTACH. Delaying the intervention until the 20th CRE detection resulted in substantial delays in achieving optimal regional prevalence, while still reducing transmissions by 60%-79% over 5 years. Conclusions Focusing intervention efforts on LTACHs is potentially a highly efficient strategy for reducing CRE transmissions across an entire region, particularly when implemented as early as possible in an emerging outbreak.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Karim Khader
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adi V Gundlapalli
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony E Fiore
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael A Rubin
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew H Samore
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
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Nosocomial Outbreak of Extensively Drug-Resistant Acinetobacter baumannii Isolates Containing blaOXA-237 Carried on a Plasmid. Antimicrob Agents Chemother 2017; 61:AAC.00797-17. [PMID: 28893775 DOI: 10.1128/aac.00797-17] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/22/2017] [Indexed: 11/20/2022] Open
Abstract
Carbapenem antibiotics are among the mainstays for treating infections caused by Acinetobacter baumannii, especially in the Northwest United States, where carbapenem-resistant A. baumannii remains relatively rare. However, between June 2012 and October 2014, an outbreak of carbapenem-resistant A. baumannii occurred in 16 patients from five health care facilities in the state of Oregon. All isolates were defined as extensively drug resistant. Multilocus sequence typing revealed that the isolates belonged to sequence type 2 (international clone 2 [IC2]) and were >95% similar as determined by repetitive-sequence-based PCR analysis. Multiplex PCR revealed the presence of a blaOXA carbapenemase gene, later identified as blaOXA-237 Whole-genome sequencing of all isolates revealed a well-supported separate branch within a global A. baumannii phylogeny. Pacific Biosciences (PacBio) SMRT sequencing was also performed on one isolate to gain insight into the genetic location of the carbapenem resistance gene. We discovered that blaOXA-237, flanked on either side by ISAba1 elements in opposite orientations, was carried on a 15,198-bp plasmid designated pORAB01-3 and was present in all 16 isolates. The plasmid also contained genes encoding a TonB-dependent receptor, septicolysin, a type IV secretory pathway (VirD4 component, TraG/TraD family) ATPase, an integrase, a RepB family plasmid DNA replication initiator protein, an alpha/beta hydrolase, and a BrnT/BrnA type II toxin-antitoxin system. This is the first reported outbreak in the northwestern United States associated with this carbapenemase. Particularly worrisome is that blaOXA-237 was carried on a plasmid and found in the most prominent worldwide clonal group IC2, potentially giving pORAB01-3 great capacity for future widespread dissemination.
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22
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Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-spectrum β-lactamase-producing Enterobacteriaceae Infections. Infect Dis Clin North Am 2017; 30:347-375. [PMID: 27208763 DOI: 10.1016/j.idc.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, which is the most common human pathogens outside of the hospital settings. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This development poses an enormous burden and threat to public health. This paper aims to narrate the evolving epidemiology of ESBL infections, and highlight current challenges in terms of management and prevention of these common infections.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Department of Internal Medicine D, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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23
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Henig O, Cober E, Richter SS, Perez F, Salata RA, Kalayjian RC, Watkins RR, Marshall S, Rudin SD, Domitrovic TN, Hujer AM, Hujer KM, Doi Y, Evans S, Fowler VG, Bonomo RA, van Duin D, Kaye KS. A Prospective Observational Study of the Epidemiology, Management, and Outcomes of Skin and Soft Tissue Infections Due to Carbapenem-Resistant Enterobacteriaceae. Open Forum Infect Dis 2017; 4:ofx157. [PMID: 29026866 PMCID: PMC5629814 DOI: 10.1093/ofid/ofx157] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/26/2017] [Indexed: 01/21/2023] Open
Abstract
Background This study was performed to characterize the epidemiology, management, and outcomes of skin and soft tissue infection (SSTI) and colonization due to carbapenem-resistant Enterobacteriaceae (CRE). Methods Patients from the Consortium on Resistance Against Carbapenem in Klebsiella and Other Enterobacteriaceae (CRACKLE-1) from December 24, 2011 to October 1, 2014 with wound cultures positive for CRE were included in the study. Predictors of surgical intervention were analyzed. Molecular typing of isolates was performed using repetitive extragenic palindromic polymerase chain reaction (PCR). Carbapenemase genes were detected using PCR. Results One hundred forty-two patients were included: 62 had SSTI (44%) and 56% were colonized. Mean age was 61 years, and 48% were male: median Charlson score was 3 (interquartile range, 1–5). Forty-eight percent of patients were admitted from long-term care facilities (LTCFs), and 31% were from the community. Two strain types (ST258A and ST258B) were identified (73% of 45 tested). Carbapenemase genes were detected in 40 of 45 isolates (blaKPC-3 [47%], blaKPC-2 [42%]). Sixty-eight patients (48%) underwent surgical intervention, 63% of whom had SSTI. Patients admitted from LTCFs were less likely to undergo surgical intervention (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.18–0.71). In multivariable analysis, among patients with SSTI, those admitted from LTCFs were less likely to undergo debridement (OR, 0.18; 95% CI, 0.04–0.93). Conclusions Patients admitted from LTCFs with CRE SSTI were less likely to undergo surgical intervention. Sixteen percent of the patients died, and approximately 50% of survivors required more intensive care upon discharge. These findings suggest a unique, impactful syndrome within the CRE infection spectrum. Further studies are needed to assess the role of surgical debridement in management of CRE-SSTI, particularly among LTCF residents.
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Affiliation(s)
- Oryan Henig
- Department of Medicine, University of Michigan, Ann Arbor; Departments of
| | | | | | - Federico Perez
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert A Salata
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Richard R Watkins
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown.,Division of Infectious Diseases, Akron General Medical Center, Ohio; Departments of
| | - Steve Marshall
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio
| | - Susan D Rudin
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Medicine
| | - T Nicholas Domitrovic
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Medicine
| | - Andrea M Hujer
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Medicine
| | - Kristine M Hujer
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Medicine
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Scott Evans
- Department of Biostatistics and the Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Vance G Fowler
- Division of Infectious Diseases and.,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Medicine.,Pharmacology.,Molecular Biology and Microbiology.,Biochemistry, and.,Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
| | - Keith S Kaye
- Department of Medicine, University of Michigan, Ann Arbor; Departments of
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Richter SS, Marchaim D. Screening for carbapenem-resistant Enterobacteriaceae: Who, When, and How? Virulence 2017; 8:417-426. [PMID: 27813699 PMCID: PMC5477693 DOI: 10.1080/21505594.2016.1255381] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022] Open
Abstract
The global spread of carbapenem-resistant Enterobacteriaceae (CRE) has been fostered by the lack of preemptive screening of patients in healthcare facilities that could prevent patient-to-patient transmission. Outbreaks of CRE infections have led some institutions to implement rigorous screening programs, although controlled comparative data are frequently lacking. Resource limitations and uncertainty regarding the optimal approach has kept many facilities from enacting more active routine surveillance policies that could reduce the prevalence of CRE. The ideal population to target for screening, the frequency of testing, and the preferred test method are components of surveillance programs that remain open to debate. This review discusses the rationale for different screening policies in use and the performance characteristics of laboratory methods available to detect CRE carriage.
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Affiliation(s)
- Sandra S. Richter
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Dror Marchaim
- Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Aliyu S, Smaldone A, Larson E. Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis. Am J Infect Control 2017; 45:512-518. [PMID: 28456321 DOI: 10.1016/j.ajic.2017.01.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/13/2017] [Accepted: 01/19/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multidrug-resistant gram-negative bacteria (MDR-GNB) are associated with an increasing proportion of infections among nursing home (NH) residents. The objective of this systematic review and meta-analysis was to critically review evidence of the prevalence of MDR-GNB among NH residents. METHODS Following Meta-Analysis of Observational Studies in Epidemiology guidelines, a systematic review of literature for the years 2005-2016 using multiple databases was conducted. Study quality, appraised by 2 reviewers, used Downs and Black risk of bias criteria. Studies reporting prevalence of MDR-GNB colonization were pooled using a random effects meta-analysis model. Heterogeneity was assessed using Cochran Q and I2 statistics. RESULTS Of 327 articles, 12 met the criteria for review; of these, 8 met the criteria for meta-analysis. Escherichia coli accounted for the largest proportion of isolates. Reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%. Pooled prevalence for MDR-GNB colonization, representing data from 2,720 NH residents, was 27% (95% confidence interval, 15.2%-44.1%) with heterogeneity (Q = 405.6; P = .01; I2 = 98.3). Two studies reported MDR-GNB infection rates of 10.9% and 62.7%. CONCLUSION Our findings suggest a high prevalence of MDR-GNB colonization among NH residents, emphasizing the need to enhance policies for infection control and prevention (ICP) in NHs.
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Affiliation(s)
- Sainfer Aliyu
- Columbia University School of Nursing, New York, NY.
| | | | - Elaine Larson
- Columbia University School of Nursing, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Adler A, Friedman ND, Marchaim D. Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications. Infect Dis Clin North Am 2016; 30:967-997. [PMID: 27660090 DOI: 10.1016/j.idc.2016.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Dror Marchaim
- Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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Kaye KS, Pogue JM. Infections Caused by Resistant Gram-Negative Bacteria: Epidemiology and Management. Pharmacotherapy 2016; 35:949-62. [PMID: 26497481 DOI: 10.1002/phar.1636] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Infections caused by resistant gram-negative bacteria are becoming increasingly prevalent and now constitute a serious threat to public health worldwide because they are difficult to treat and are associated with high morbidity and mortality rates. In the United States, there has been a steady increase since 2000 in rates of extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii, particularly among hospitalized patients with intraabdominal infections, urinary tract infections, ventilator-associated pneumonia, and bacteremia. Colonization with resistant gram-negative bacteria is common among residents in long-term care facilities (particularly those residents with an indwelling device), and these facilities are considered important originating sources of such strains for hospitals. Antibiotic resistance is associated with a substantial clinical and economic burden, including increased mortality, greater hospital and antibiotic costs, and longer stays in hospitals and intensive care units. Control of resistant gram-negative infections requires a comprehensive approach, including strategies for risk factor identification, detection and identification of resistant organisms, and implementation of infection-control and prevention strategies. In treating resistant gram-negative infections, a review of surveillance data and hospital-specific antibiograms, including resistance patterns within local institutions, and consideration of patient characteristics are helpful in guiding the choice of empiric therapy. Although only a few agents are available with activity against resistant gram-negative organisms, two recently released β-lactam/β-lactamase inhibitor combinations - ceftolozane/tazobactam and ceftazidime/avibactam - have promising activity against these organisms. In this article, we review the epidemiology, risk factors, and antibiotic resistance mechanisms of gram-negative organisms. In addition, an overview of treatment options for patients with these infections is provided.
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Affiliation(s)
- Keith S Kaye
- Department of Medicine, Detroit Medical Center and Wayne State University, University Health Center, Detroit, Michigan
| | - Jason M Pogue
- Department of Pharmacy, Sinai-Grace Hospital, Detroit Medical Center and Wayne State University School of Medicine, Detroit, Michigan
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The Epidemiology of Carbapenem-Resistant Klebsiella pneumoniae Colonization and Infection among Long-Term Acute Care Hospital Residents. Infect Control Hosp Epidemiol 2015; 37:55-60. [PMID: 26455382 DOI: 10.1017/ice.2015.254] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE An improved understanding of carbapenem-resistant Klebsiella pneumoniae (CRKP) in long-term acute care hospitals (LTACHs) is needed. The objective of this study was to assess risk factors for colonization or infection with CRKP in LTACH residents. METHODS A case-control study was performed at a university-affiliated LTACH from 2008 to 2013. Cases were defined as all patients with clinical cultures positive for CRKP and controls were those with clinical cultures positive for carbapenem-susceptible K. pneumoniae (CSKP). A multivariate model was developed to identify risk factors for CRKP infection or colonization. RESULTS A total of 222 patients were identified with K. pneumoniae clinical cultures during the study period; 99 (45%) were case patients and 123 (55%) were control patients. Our multivariate analysis identified factors associated with a significant risk for CRKP colonization or infection: solid organ or stem cell transplantation (OR, 5.05; 95% CI, 1.23-20.8; P=.03), mechanical ventilation (OR, 2.56; 95% CI, 1.24-5.28; P=.01), fecal incontinence (OR, 5.78; 95% CI, 1.52-22.0; P=.01), and exposure in the prior 30 days to meropenem (OR, 3.55; 95% CI, 1.04-12.1; P=.04), vancomycin (OR, 2.94; 95% CI, 1.18-7.32; P=.02), and metronidazole (OR, 4.22; 95% CI, 1.28-14.0; P=.02). CONCLUSIONS Rates of colonization and infection with CRKP were high in the LTACH setting, with nearly half of K. pneumoniae cultures demonstrating carbapenem resistance. Further studies are needed on interventions to limit the emergence of CRKP in LTACHs, including targeted surveillance screening of high-risk patients and effective antibiotic stewardship measures. Infect. Control Hosp. Epidemiol. 2015;37(1):55-60.
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The Complex Epidemiology of Carbapenem-Resistant Enterobacter Infections: A Multicenter Descriptive Analysis. Infect Control Hosp Epidemiol 2015; 36:1283-91. [PMID: 26399907 DOI: 10.1017/ice.2015.186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The pandemic of carbapenem-resistant Enterobacteriaceae (CRE) was primarily due to clonal spread of bla KPC producing Klebsiella pneumoniae. Thus, thoroughly studied CRE cohorts have consisted mostly of K. pneumoniae. OBJECTIVE To conduct an extensive epidemiologic analysis of carbapenem-resistant Enterobacter spp. (CREn) from 2 endemic and geographically distinct centers. METHODS CREn were investigated at an Israeli center (Assaf Harofeh Medical Center, January 2007 to July 2012) and at a US center (Detroit Medical Center, September 2008 to September 2009). bla KPC genes were queried by polymerase chain reaction. Repetitive extragenic palindromic polymerase chain reaction and pulsed-field gel electrophoresis were used to determine genetic relatedness. RESULTS In this analysis, 68 unique patients with CREn were enrolled. Sixteen isolates (24%) were from wounds, and 33 (48%) represented colonization only. All isolates exhibited a positive Modified Hodge Test, but only 93% (27 of 29) contained bla KPC. Forty-three isolates (63%) were from elderly adults, and 5 (7.4%) were from neonates. Twenty-seven patients died in hospital (40.3% of infected patients). Enterobacter strains consisted of 4 separate clones from Assaf Harofeh Medical Center and of 4 distinct clones from Detroit Medical Center. CONCLUSIONS In this study conducted at 2 distinct CRE endemic regions, there were unique epidemiologic features to CREn: (i) polyclonality, (ii) neonates accounting for more than 7% of cohort, and (iii) high rate of colonization (almost one-half of all cases represented colonization). Since false-positive Modified Hodge Tests in Enterobacter spp. are common, close monitoring of carbapenem resistance mechanisms (particularly carbapenemase production) among Enterobacter spp. is important.
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Ridolfo AL, Rimoldi SG, Pagani C, Marino AF, Piol A, Rimoldi M, Olivieri P, Galli M, Dolcetti L, Gismondo MR. Diffusion and transmission of carbapenem-resistant Klebsiella pneumoniae in the medical and surgical wards of a university hospital in Milan, Italy. J Infect Public Health 2015; 9:24-33. [PMID: 26116453 DOI: 10.1016/j.jiph.2015.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/04/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is emerging as a public health problem worldwide. In Italy, a remarkable increase in CRKP cases has been reported since 2010. In this study, CRKP diffusion, distribution and in-hospital transmission trends were evaluated in a university hospital in Milan, Italy, from January 2012 to December 2013. Isolates from 63 newly detected CRKP-positive patients were genotyped, and possible transmission was determined by combining the molecular results with data concerning the patients' admission and in-hospital transfers. Most of the cases (90.4%) were from general medical and surgery wards, and the remaining 9.6% were from the intensive care unit. Fifteen of the 46 hospital-associated cases (32.6%) were attributable to in-hospital transmission. After the introduction of targeted and hospital-wide control measures, the transmission index significantly decreased from 0.65 to 0.13 (p=0.01). There was also a decrease in the overall nosocomial case incidence, from 0.37 to 0.17 per 1000 person-days (p=0.07). Our findings indicate that the spread of CRKP in Northern Italy hospitals may go far beyond high-risk settings (i.e., intensive care units) and that strict surveillance should be extended to general areas of care.
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Affiliation(s)
- Anna L Ridolfo
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy; Sezione di Malattie Infettive e Immunopatologia, Dipartimento di Scienze Cliniche, Ospedale Luigi Sacco, Università degli Studi di Milano, Via G.B. Grassi 74, 20156 Milano, Italy.
| | - Sara G Rimoldi
- Laboratorio di Microbiologia Clinica, Virologia e Diagnostica Bioemergenze, Ospedale Luigi Sacco, Università degli Studi di Milano, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Cristina Pagani
- Laboratorio di Microbiologia Clinica, Virologia e Diagnostica Bioemergenze, Ospedale Luigi Sacco, Università degli Studi di Milano, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Andrea F Marino
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Anna Piol
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Matteo Rimoldi
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Pietro Olivieri
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Massimo Galli
- Sezione di Malattie Infettive e Immunopatologia, Dipartimento di Scienze Cliniche, Ospedale Luigi Sacco, Università degli Studi di Milano, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Lucia Dolcetti
- Direzione Medica di Presidio, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Via G.B. Grassi 74, 20156 Milano, Italy
| | - Maria R Gismondo
- Laboratorio di Microbiologia Clinica, Virologia e Diagnostica Bioemergenze, Ospedale Luigi Sacco, Università degli Studi di Milano, Via G.B. Grassi 74, 20156 Milano, Italy
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Residence in Skilled Nursing Facilities Is Associated with Tigecycline Nonsusceptibility in Carbapenem-Resistant Klebsiella pneumoniae. Infect Control Hosp Epidemiol 2015; 36:942-8. [PMID: 25990806 DOI: 10.1017/ice.2015.118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the rates of and risk factors for tigecycline nonsusceptibility among carbapenem-resistant Klebsiella pneumoniae (CRKPs) isolated from hospitalized patients. DESIGN Multicenter prospective observational study. SETTING Acute care hospitals participating in the Consortium on Resistance against Carbapenems in Klebsiella pneumoniae (CRaCKle). PATIENTS A cohort of 287 patients who had CRKPs isolated from clinical cultures during hospitalization. METHODS For the period from December 24, 2011 to October 1, 2013, the first hospitalization of each patient with a CRKP during which tigecycline susceptibility for the CRKP isolate was determined was included. Clinical data were entered into a centralized database, including data regarding pre-hospital origin. Breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used to interpret tigecycline susceptibility testing. RESULTS Of 287 patients included in the final cohort, 155 (54%) had tigecycline-susceptible CRKPs. Of all index isolates, 81 (28%) were tigecycline-intermediate and 51 (18%) were tigecycline resistant. In multivariate modeling, independent risk factors for tigecycline nonsusceptibility were (1) admission from a skilled nursing facility (OR, 2.51; 95% CI, 1.51-4.21; P=.0004), (2) positive culture within 2 days of admission (OR, 1.82; 95% CI, 1.06-3.15; P=.03), and (3) receipt of tigecycline within 14 days (OR, 4.38, 95% CI, 1.37-17.01, P=.02). CONCLUSIONS In hospitalized patients with CRKPs, tigecycline nonsusceptibility was more frequently observed in those admitted from skilled nursing facilities and occurred earlier during hospitalization. Skilled nursing facilities are an important target for interventions to decrease antibacterial resistance to antibiotics of last resort for treatment of CRKPs.
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Tal Jasper R, Coyle JR, Katz DE, Marchaim D. The complex epidemiology of extended-spectrum β-lactamase-producing Enterobacteriaceae. Future Microbiol 2015; 10:819-39. [DOI: 10.2217/fmb.15.16] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
ABSTRACT Antimicrobial resistance is a growing worldwide iatrogenic complication of modern medical care. Extended-spectrum β-lactamases have emerged as one of the most successful resistance mechanisms, limiting our therapeutic options to treat various human infections. The dissemination of these enzymes to the community probably signifies an irreversible step. This paper will review the evolution of human infections associated with extended-spectrum β-lactamase-producing organisms in the past 20 years, and will present and discuss the current challenges, controversies, debates and knowledge gaps in this research field.
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Affiliation(s)
- Ruthy Tal Jasper
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Joseph R Coyle
- Division of Communicable Diseases, Bureau of Disease Control, Prevention & Epidemiology, Michigan Department of Community Health, 201 Townsend St, Lansing, MI, USA, 48909
| | - David E Katz
- Department of Internal Medicine D, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
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Pogue J, Kaye K, Cohen D, Marchaim D. Appropriate antimicrobial therapy in the era of multidrug-resistant human pathogens. Clin Microbiol Infect 2015; 21:302-12. [DOI: 10.1016/j.cmi.2014.12.025] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 12/22/2014] [Accepted: 12/27/2014] [Indexed: 01/02/2023]
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Ben-David D, Masarwa S, Adler A, Mishali H, Carmeli Y, Schwaber MJ. A national intervention to prevent the spread of carbapenem-resistant Enterobacteriaceae in Israeli post-acute care hospitals. Infect Control Hosp Epidemiol 2015; 35:802-9. [PMID: 24915207 DOI: 10.1086/676876] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients hospitalized in post-acute care hospitals (PACHs) constitute an important reservoir of antimicrobial-resistant bacteria. High carriage prevalence of carbapenem-resistant Enterobacteriaceae (CRE) has been observed among patients hospitalized in PACHs. The objective of the study is to describe the impact of a national infection control intervention on the prevalence of CRE in PACHs. DESIGN A prospective cohort interventional study. SETTING Thirteen PACHs in Israel. INTERVENTION A multifaceted intervention was initiated between 2008 and 2011 as part of a national program involving all Israeli healthcare facilities. The intervention has included (1) periodic on-site assessments of infection control policies and resources, using a score comprised of 16 elements; (2) assessment of risk factors for CRE colonization; (3) development of national guidelines for CRE control in PACHs involving active surveillance and contact isolation of carriers; and (4) 3 cross-sectional surveys of rectal carriage of CRE that were conducted in representative wards. RESULTS The infection control score increased from 6.8 to 14.0 (P < .001) over the course of the study period. A total of 3,516 patients were screened in the 3 surveys. Prevalence of carriage among those not known to be carriers decreased from 12.1% to 7.9% (P = .008). Overall carrier prevalence decreased from 16.8% to 12.5% (P = .013). Availability of alcohol-based hand rub, appropriate use of gloves, and a policy of CRE surveillance at admission to the hospital were independently associated with lower new carrier prevalence. CONCLUSION A nationwide infection control intervention was associated with enhanced infection control measures and a reduction in the prevalence of CRE in PACHs.
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Affiliation(s)
- Debby Ben-David
- National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
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Cheng VCC, Wong SCY, Ho PL, Yuen KY. Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China. Emerg Microbes Infect 2015; 4:e8. [PMID: 26038766 PMCID: PMC4345289 DOI: 10.1038/emi.2015.8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/30/2014] [Accepted: 12/30/2014] [Indexed: 01/23/2023]
Abstract
Antimicrobial-resistant bacteria are either highly prevalent or increasing rapidly in Hong Kong and China. Treatment options for these bacteria are generally limited, less effective and more expensive. The emergence and dynamics of antimicrobial resistance genes in bacteria circulating between animals, the environment and humans are not entirely known. Nonetheless, selective pressure by antibiotics on the microbiomes of animal and human, and their associated environments (especially farms and healthcare institutions), sewage systems and soil are likely to confer survival advantages upon bacteria with antimicrobial-resistance genes, which may be further disseminated through plasmids or transposons with integrons. Therefore, antibiotic use must be tightly regulated to eliminate such selective pressure, including the illegalization of antibiotics as growth promoters in animal feed and regulation of antibiotic use in veterinary practice and human medicine. Heightened awareness of infection control measures to reduce the risk of acquiring resistant bacteria is essential, especially during antimicrobial use or institutionalization in healthcare facilities. The transmission cycle must be interrupted by proper hand hygiene, environmental cleaning, avoidance of undercooked or raw food and compliance with infection control measures by healthcare workers, visitors and patients, especially during treatment with antibiotics. In addition to these routine measures, proactive microbiological screening of hospitalized patients with risk factors for carrying resistant bacteria, including history of travel to endemic countries, transfer from other hospitals, and prolonged hospitalization; directly observed hand hygiene before oral intake of drugs, food and drinks; and targeted disinfection of high-touch or mutual-touch items, such as bed rails and bed curtains, are important. Transparency of surveillance data from each institute for public scrutiny provides an incentive for controlling antimicrobial resistance in healthcare settings at an administrative level.
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Affiliation(s)
- Vincent C C Cheng
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China ; Infection Control Team, Queen Mary Hospital , Hong Kong, China
| | - Sally C Y Wong
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China
| | - Pak-Leung Ho
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China
| | - Kwok-Yung Yuen
- Department of Microbiology, Queen Mary Hospital, Hong Kong, China ; Department of Clinical Microbiology and Infection Control, Hong Kong University-Shenzhen Hospital , Shenzhen 518053, Guangdong province, China
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Savard P, Carroll KC, Wilson LE, Perl TM. The Challenges of Carbapenemase-Producing Enterobacteriaceae and Infection Prevention: Protecting Patients in the Chaos. Infect Control Hosp Epidemiol 2015; 34:730-9. [DOI: 10.1086/671003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Hayden MK, Lin MY, Lolans K, Weiner S, Blom D, Moore NM, Fogg L, Henry D, Lyles R, Thurlow C, Sikka M, Hines D, Weinstein RA. Prevention of colonization and infection by Klebsiella pneumoniae carbapenemase-producing enterobacteriaceae in long-term acute-care hospitals. Clin Infect Dis 2014; 60:1153-61. [PMID: 25537877 DOI: 10.1093/cid/ciu1173] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (hereafter "KPC") are an increasing threat to healthcare institutions. Long-term acute-care hospitals (LTACHs) have especially high prevalence of KPC. METHODS Using a stepped-wedge design, we tested whether a bundled intervention (screening patients for KPC rectal colonization upon admission and every other week; contact isolation and geographic separation of KPC-positive patients in ward cohorts or single rooms; bathing all patients daily with chlorhexidine gluconate; and healthcare-worker education and adherence monitoring) would reduce colonization and infection due to KPC in 4 LTACHs with high endemic KPC prevalence. The study was conducted between 1 February 2010 and 30 June 2013; 3894 patients were enrolled during the preintervention period (lasting from 16 to 29 months), and 2951 patients were enrolled during the intervention period (lasting from 12 to 19 months). RESULTS KPC colonization prevalence was stable during preintervention (average, 45.8%; 95% confidence interval [CI], 42.1%-49.5%), declined early during intervention, then reached a plateau (34.3%; 95% CI, 32.4%-36.2%; P<.001 for exponential decline). During intervention, KPC admission prevalence remained high (average, 20.6%, 95% CI, 19.1%-22.3%). The incidence rate of KPC colonization fell during intervention, from 4 to 2 acquisitions per 100 patient-weeks (P=.004 for linear decline). Compared to preintervention, average rates of clinical outcomes declined during intervention: KPC in any clinical culture (3.7 to 2.5/1000 patient-days; P=.001), KPC bacteremia (0.9 to 0.4/1000 patient-days; P=.008), all-cause bacteremia (11.2 to 7.6/1000 patient-days; P=.006) and blood culture contamination (4.9 to 2.3/1000 patient-days; P=.03). CONCLUSIONS A bundled intervention was associated with clinically important and statistically significant reductions in KPC colonization, KPC infection, all-cause bacteremia, and blood culture contamination in a high-risk LTACH population.
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Affiliation(s)
- Mary K Hayden
- Departments of Medicine, Division of Infectious Diseases Pathology
| | - Michael Y Lin
- Departments of Medicine, Division of Infectious Diseases
| | | | - Shayna Weiner
- Departments of Medicine, Division of Infectious Diseases
| | - Donald Blom
- Departments of Medicine, Division of Infectious Diseases
| | | | | | - David Henry
- Department of Biostatistics, University of Illinois School of Public Health
| | - Rosie Lyles
- Department of Medicine, Division of Infectious Diseases, Cook County Health and Hospital System
| | | | - Monica Sikka
- Departments of Medicine, Division of Infectious Diseases
| | - David Hines
- Metro Infectious Disease Consultants LLC, Chicago, Illinois
| | - Robert A Weinstein
- Departments of Medicine, Division of Infectious Diseases Department of Medicine, Division of Infectious Diseases, Cook County Health and Hospital System
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Brennan BM, Coyle JR, Marchaim D, Pogue JM, Boehme M, Finks J, Malani AN, VerLee KE, Buckley BO, Mollon N, Sundin DR, Washer LL, Kaye KS. Statewide surveillance of carbapenem-resistant enterobacteriaceae in Michigan. Infect Control Hosp Epidemiol 2014; 35:342-9. [PMID: 24602937 DOI: 10.1086/675611] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan. METHODS The Michigan Department of Community Health-led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month. RESULTS One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins. CONCLUSIONS CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.
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Affiliation(s)
- Brenda M Brennan
- Division of Communicable Diseases, Bureau of Disease Control, Prevention and Epidemiology, Michigan Department of Community Health, Lansing, Michigan
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Guh AY, Limbago BM, Kallen AJ. Epidemiology and prevention of carbapenem-resistant Enterobacteriaceae in the United States. Expert Rev Anti Infect Ther 2014; 12:565-80. [PMID: 24666262 PMCID: PMC6494086 DOI: 10.1586/14787210.2014.902306] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant organisms with few treatment options that cause infections associated with substantial morbidity and mortality. CRE outbreaks have been increasingly reported worldwide and are mainly due to the emergence and spread of strains that produce carbapenemases. In the United States, transmission of CRE is primarily driven by the spread of organisms carrying the Klebsiella pneumoniae carbapenemase enzyme, but other carbapenemase enzymes, such as the New-Delhi metallo-β-lactamase, have also emerged. Currently recommended control strategies for healthcare facilities include the detection of patients infected or colonized with CRE and implementation of measures to prevent further spread. In addition to efforts in individual facilities, effective CRE control requires coordination across all healthcare facilities in a region. This review describes the current epidemiology and surveillance of CRE in the United States and the recommended approach to prevention.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brandi M Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Meddings J, Rogers MAM, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014; 23:277-89. [PMID: 24077850 PMCID: PMC3960353 DOI: 10.1136/bmjqs-2012-001774] [Citation(s) in RCA: 242] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 05/16/2013] [Accepted: 07/26/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use. METHODS To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation. RESULTS 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs. CONCLUSIONS UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.
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Affiliation(s)
- Jennifer Meddings
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mary A M Rogers
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Mohamad G Fakih
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan, USA
| | | | - Sanjay Saint
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Lin MY, Lyles-Banks RD, Lolans K, Hines DW, Spear JB, Petrak R, Trick WE, Weinstein RA, Hayden MK. The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2013; 57:1246-52. [PMID: 23946222 DOI: 10.1093/cid/cit500] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND In the United States, Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are increasingly detected in clinical infections; however, the colonization burden of these organisms among short-stay and long-term acute care hospitals is unknown. METHODS Short-stay acute care hospitals with adult intensive care units (ICUs) in the city of Chicago were recruited for 2 cross-sectional single-day point prevalence surveys (survey 1, July 2010-January 2011; survey 2, January-July 2011). In addition, all long-term acute care hospitals (LTACHs) in the Chicago region (Cook County) were recruited for a single-day point prevalence survey during January-May 2011. Swab specimens were collected from rectal, inguinal, or urine sites and tested for Enterobacteriaceae carrying blaKPC. RESULTS We surveyed 24 of 25 eligible short-stay acute care hospitals and 7 of 7 eligible LTACHs. Among LTACHs, 30.4% (119 of 391) of patients were colonized with KPC-producing Enterobacteriaceae, compared to 3.3% (30 of 910) of short-stay hospital ICU patients (prevalence ratio, 9.2; 95% confidence interval, 6.3-13.5). All surveyed LTACHs had patients harboring KPC (prevalence range, 10%-54%), versus 15 of 24 short-stay hospitals (prevalence range, 0%-29%). Several patient-level covariates present at the time of survey-LTACH facility type, mechanical ventilation, and length of stay-were independent risk factors for KPC-producing Enterobacteriaceae colonization. CONCLUSIONS We identified high colonization prevalence of KPC-producing Enterobacteriaceae among patients in LTACHs. Patients with chronic medical care needs in long-term care facilities may play an important role in the spread of these extremely drug-resistant pathogens.
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Affiliation(s)
- Michael Y Lin
- Department of Medicine, Rush University Medical Center
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Bogan C, Marchaim D. The role of antimicrobial stewardship in curbing carbapenem resistance. Future Microbiol 2013; 8:979-91. [DOI: 10.2217/fmb.13.73] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Antimicrobial resistance is a continuing, growing, worldwide iatrogenic complication of modern medical care. Carbapenem resistance among certain pathogens poses a significant challenge. In order to reduce the spread of these nearly untreatable pathogens, preventative efforts should be directed at reducing patient-to-patient transmission and preventing the emergence of resistance among susceptible strains. One theoretical intervention to reduce the emergence of resistance is establishing and strictly adhering to an antimicrobial stewardship program. However, data pertaining to the direct effect of stewardship in curtailing carbapenem resistance among epidemiologically significant organisms are scarce. In this report, we review the potential biases associated with data interpretation in this research field, and we review the data pertaining to the impact of stewardship in curbing carbapenem resistance in three significant groups of pathogens: Pseudomonas aeruginosa, Enterobacteriaceae and Acinetobacter baumannii.
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Affiliation(s)
| | - Dror Marchaim
- Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Marchaim D, Katz DE, Munoz-Price LS. Emergence and Control of Antibiotic-resistant Gram-negative Bacilli in Older Adults. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13670-013-0051-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Molecular surveillance and clinical outcomes of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae infections. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012. [PMID: 23200553 DOI: 10.1016/j.jmii.2012.08.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE The emergence of carbapenem-resistant Enterobacteriaceae (CRE) is a cause for great concern. The aim of this study was to evaluate antimicrobial susceptibility, mechanisms of carbapenem-resistance in two members of the Enterobacteriaceae family (Escherichia coli and Klebsiella pneumoniae), and clinical outcomes of their infections. METHODS The susceptibility tests of 16 E. coli and 60 K. pneumoniae isolates, collected from 2010 to 2011, were assessed. The minimal inhibitory concentrations of eight antimicrobial agents were assessed by the broth microdilution method according to the recommendations of the Clinical and Laboratory Standards Institute. The detection of beta-lactamase genes was performed by polymerase chain reaction. The genetic relatedness of these isolates was determined by pulsed-field gel electrophoresis (PFGE) fingerprinting. RESULTS The carbapenemase genes blaKPC-2 and blaOxA were detected in one and five K. pneumoniae isolates, respectively. The genetic combinations blaSHV-5-blaDHA and blaSHV-5-blaCTx-M-G9 were prevalent in 45% and 26.7% of 60 K. pneumoniae isolates, respectively. The susceptibility rates of 60 K. pneumoniae isolates to colistin and tigecycline were 58.3% and 50.0%, respectively. The 30-day mortality rates of the patients treated with carbapenem, colistin, or tigecycline were as high as 60.6%. Nine clusters of K. pneumoniae isolates were identified by PFGE fingerprinting. CONCLUSION The findings of carbapenemase genes in a few isolates and small clusters of CRE indicated the emerging problems in the hospital. The high mortality rates were observed in the patients treated by colistin and tigecycline, although they were the only alternative treatment options for CRE infections. Active surveillance and an effective infection control strategy should be implemented to control the spread of CRE infections.
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