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Giannella M, Pascale R, Viale P. Progression From Carriage to Bloodstream Infection and Fatality by Different Enterobacterales Species, Carbapenemases, and Host Settings: Deciphering the Melting Pot. Clin Infect Dis 2024; 79:30-32. [PMID: 38447000 DOI: 10.1093/cid/ciae109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Maddalena Giannella
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences, University of Bologna, Italy
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Kim KR, Park HJ, Baek SY, Choi SH, Lee BK, Kim S, Kim JM, Kang JM, Kim SJ, Choi SR, Kim D, Choi JS, Yoon Y, Park H, Kim DR, Shin A, Kim S, Kim YJ. The Impact of an Antimicrobial Stewardship Program on Days of Therapy in the Pediatric Center: An Interrupted Time-Series Analysis of a 19-Year Study. J Korean Med Sci 2024; 39:e172. [PMID: 38832477 PMCID: PMC11147790 DOI: 10.3346/jkms.2024.39.e172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND We aimed to analyze the effects of an antimicrobial stewardship program (ASP) on the proportion of antimicrobial-resistant pathogens in bacteremia, antimicrobial use, and mortality in pediatric patients. METHODS A retrospective single-center study was performed on pediatric inpatients under 19 years old who received systemic antimicrobial treatment from 2001 to 2019. A pediatric infectious disease attending physician started ASP in January 2008. The study period was divided into the pre-intervention (2001-2008) and the post-intervention (2009-2019) periods. The amount of antimicrobial use was defined as days of therapy per 1,000 patient-days, and the differences were compared using delta slope (= changes in slopes) between the two study periods by an interrupted time-series analysis. The proportion of resistant pathogens and the 30-day overall mortality rate were analyzed by the χ². RESULTS The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae bacteremia increased from 17% (39 of 235) in the pre-intervention period to 35% (189 of 533) in the post-intervention period (P < 0.001). The total amount of antimicrobial use significantly decreased after the introduction of ASP (delta slope value = -16.5; 95% confidence interval [CI], -30.6 to -2.3; P = 0.049). The 30-day overall mortality rate in patients with bacteremia did not increase, being 10% (55 of 564) in the pre-intervention and 10% (94 of 941) in the post-intervention period (P = 0.881). CONCLUSION The introduction of ASP for pediatric patients reduced the delta slope of the total antimicrobial use without increasing the mortality rate despite an increased incidence of ESBL-producing gram-negative bacteremia.
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Affiliation(s)
- Kyung-Ran Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo Jung Park
- Department of Pharmacy, Samsung Medical Center, Seoul, Korea
- Sungkyunkwan University School of Pharmacy, Suwon, Korea
| | - Sun-Young Baek
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung-Kee Lee
- Department of Pediatrics, Seoulsan Boram Hospital, Ulsan, Korea
| | - SooJin Kim
- Samsung Dream Pediatric Clinic, Suwon, Korea
| | - Jong Min Kim
- Department of Pediatrics, Myongji Hospital, Goyang, Korea
| | - Ji-Man Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Ja Kim
- Samsung Dream Pediatric Clinic, Jeju, Korea
| | | | - Dongsub Kim
- Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Joon-Sik Choi
- Department of Pediatrics, Gangnam Severance Hospital, Seoul, Korea
| | - Yoonsun Yoon
- Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hwanhee Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Doo Ri Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Areum Shin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seonwoo Kim
- Academic Research Service Headquarter, LSK Global PS, Seoul, Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Seoul, Korea.
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3
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Li Y, Ma L, Ding X, Zhang R. Fecal carriage and genetic characteristics of carbapenem-resistant enterobacterales among adults from four provinces of China. FRONTIERS IN EPIDEMIOLOGY 2024; 3:1304324. [PMID: 38455926 PMCID: PMC10910981 DOI: 10.3389/fepid.2023.1304324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/12/2023] [Indexed: 03/09/2024]
Abstract
Carbapenem-resistant Enterobacterales (CRE) is a global concern. This study investigated the prevalence of fecal colonization carriage and clonal dissemination of CRE among population in four provinces of China. A total of 685 stool samples were collected from four provinces in China. Among these samples, 141 and 544 were obtained from healthy and hospitalized individuals, respectively. The overall fecal carriage rate was 9.6% (65/685) with 4.26% (95% CI: 0.9-7.6) in healthy individuals and 10.84% (95% CI: 8.2-13.5) in hospitalized patients. The highest prevalence was in Henan province (18.35%, 95% CI: 9%-18.7%). Sixty-six CRE isolates were identified in Escherichia coli (56.06%, 37/66), Klebsiella (15.15%, 10/66), Citrobacter (13.63%, 9/66), Enterobacter (12.12%, 8/66), and Atlantibacter (1.51%, 1/66). All CRE strains carried carbapenemase genes and multiple antibiotics resistance genes, blaNDM-5 (77.27%, 51/66) was the most common carbapenemase gene, followed by blaNDM-1 (19.69%, 13/66). Antibiotic resistance genes, including blaIMP-4, and the colistin colistin resistance (mcr-1) gene were also identified. All CRE isolates belonged to different sequence types (STs). ST206 (36.84%, 14/38) in E. coli and ST2270 (60%, 6/10) in Klebsiella were significantly dominant clones. The results indicated the prevalence of CRE fecal carriage among adults of China, mostly blaNDM-producing E coli, which pose significant challenges for clinical management. Screening for CRE colonization is necessary to control infection.
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Affiliation(s)
- Yuanyuan Li
- Department of Clinical Laboratory, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Lan Ma
- Department of Clinical Laboratory, Second Affiliated Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Xinying Ding
- Department of Clinical Laboratory, Zibo First Hospital, Zibo, Shandong, China
| | - Rong Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
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4
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Biagetti C, Tatarelli P, Tebano G, Casolari S, Fantini M, Malavolti M, Amadori A, Tura GA, Sambri V, Minghetti M, Grilli R, Gagliotti C. Containment of carbapenem-resistant Enterobacterales colonisations and infections: Results from an integrated infection control intervention in a large hospital trust of northern Italy. Am J Infect Control 2024; 52:66-72. [PMID: 37543306 DOI: 10.1016/j.ajic.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE We describe the results of an infection control intervention, implemented in 4 tertiary hospitals in Romagna, Italy, aiming at containing the spread of carbapenem-resistant Enterobacterales (CRE). METHODS The intervention consisted of rectal screening in patients at risk for CRE; pre-emptive contact precaution waiting for screening results; timely notification of CRE identification and concomitant computerized alert; contact precaution for confirmed CRE-positive patients. We performed an interrupted time series analysis to compare the incidence of CRE bacteraemia, of other CRE infections, and CRE-positive rectal swabs in the pre and postintervention period (January 2015-July 2017 and August 2017-June 2020, respectively). RESULTS 4,332 CRE isolates were collected. Klebsiella pneumoniae was the most represented pathogen (n = 3,716, 85%); KPC production was the most common resistance mechanism (n = 3,896, 90%). The incidence rate of CRE bacteraemia significantly decreased from 0.554 to 0.447 episodes per 10.000 patient days in the early postintervention period (P = .001). The incidence rate of other CRE infections significantly decreased from 2.09 to 1.49 isolations per 10.000 patient days in the early postintervention period (P = .021). The monthly number of rectal swabs doubled in the postintervention period and there was a significant reduction trend of CRE-positive swabs, sustained over time (P < .001). CONCLUSIONS The infection control intervention was successful in containing the spread of CRE infections and colonisations.
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Affiliation(s)
- C Biagetti
- Division of Infectious diseases, Infermi Hospital, Rimini, AUSL Romagna, Italy
| | - P Tatarelli
- Division of Infectious diseases, Santa Maria delle Croci Hospital, Ravenna, AUSL Romagna, Italy.
| | - G Tebano
- Division of Infectious diseases, Santa Maria delle Croci Hospital, Ravenna, AUSL Romagna, Italy
| | - S Casolari
- Division of Infectious diseases, Santa Maria delle Croci Hospital, Ravenna, AUSL Romagna, Italy
| | - M Fantini
- U.O. Ricerca Valutativa e Policy Servizi Sanitari AUSL Romagna, Italy
| | - M Malavolti
- Hospital Direction, Santa Maria delle Croci Hospital, Ravenna, AUSL Romagna, Italy
| | - A Amadori
- Hospital Direction, G.B. Morgagni-L. Pierantoni Hospital, Forlì, AUSL Romagna, Italy
| | - G A Tura
- Hospital Direction, Infermi Hospital, Rimini, AUSL Romagna, Italy
| | - V Sambri
- Microbiologia AUSL della Romagna, Cesena, Italy
| | - M Minghetti
- Hospital Direction, M. Bufalini Hospital, Cesena, Italy
| | - R Grilli
- U.O. Ricerca Valutativa e Policy Servizi Sanitari AUSL Romagna, Italy
| | - C Gagliotti
- Agenzia Sanitaria e Sociale Regionale-Regione Emilia-Romagna, Bologna, Italy
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Fasciana T, Antonelli A, Bianco G, Lombardo D, Codda G, Roscetto E, Perez M, Lipari D, Arrigo I, Galia E, Tricoli MR, Calvo M, Niccolai C, Morecchiato F, Errico G, Stefani S, Cavallo R, Marchese A, Catania MR, Ambretti S, Rossolini GM, Pantosti A, Palamara AT, Sabbatucci M, Serra N, Giammanco A. Multicenter study on the prevalence of colonization due to carbapenem-resistant Enterobacterales strains before and during the first year of COVID-19, Italy 2018-2020. Front Public Health 2023; 11:1270924. [PMID: 38186699 PMCID: PMC10771343 DOI: 10.3389/fpubh.2023.1270924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background Among multidrug-resistant (MDR) bacteria able to threaten human health, carbapenem-resistant Enterobacterales (CRE) have become a major public health threat globally. National and international guidelines point out the importance of active routine surveillance policies to prevent CRE transmission. Therefore, defining lines of intervention and strategies capable of containing and controlling the spread of CRE is considered determinant. CRE screening is one of the main actions to curb transmission and control outbreaks, outlining the presence and also the prevalence and types of carbapenemase enzymes circulating locally. Objective The purpose of this study was to outline the epidemiology of CRE colonization in Italy, detecting CRE-colonized patients at admission and during hospitalization, before and during the first year of COVID-19. Materials and methods A total of 11,063 patients admitted to seven different hospitals (Bologna, Catania, Florence, Genoa, Naples, Palermo, and Turin) in Intensive Care Units (ICU) and other wards (non-ICU) located in the North, Center, and South of Italy were enrolled and screened for CRE carriage at admission (T0) and during the first 3 weeks of hospitalization (T1-T3). The study spanned two periods, before (September 2018-Septemeber 2019, I observational period) and during the COVID-19 pandemic (October 2019-September 2020, II observational period). Results Overall, the prevalence of CRE-colonized patients at admission in ICU or in other ward, ranged from 3.9 to 11.5%, while a percentage from 5.1 to 15.5% of patients acquired CRE during hospital stay. There were large differences between the I and II period of study according to the different geographical areas and enrolling centers. Overall, comparison of prevalence of CRE-positive patients showed a significant increased trend between I and II observational periods both in ICU and non-ICU wards, mostly in the Southern participating centers. KPC-producing Klebsiella pneumoniae was the most frequent CRE species-carbapenemase combination reported in this study. In particular, the presence of KPC-producing K. pneumoniae was reported in period I during hospitalization in all the CRE-positive patients enrolled in ICU in Turin (North Italy), while in period II at admission in all the CRE-positive patients enrolled in ICU in Catania and in 58.3% of non-ICU CRE-positive patients in Naples (both centers in South Italy). Conclusion The prevalence of CRE in Italy highly increased during the COVID-19 pandemic, mostly in the Southern hospital centers. KPC-producing K. pneumoniae was the most frequent colonizing CRE species reported. The results of our study confirmed the crucial value of active surveillance as well as the importance of multicenter studies representing diverse geographical areas even in endemic countries. Differences in CRE colonization prevalence among centers suggest the need for diversified and center-specific interventions as well as for strengthening efforts in infection prevention and control practices and policies.
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Affiliation(s)
- Teresa Fasciana
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Alberto Antonelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Gabriele Bianco
- University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Donatella Lombardo
- Unit of Microbiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Codda
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy
| | - Emanuela Roscetto
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Marianna Perez
- Department of Biomedical and Biotechnological Sciences, University Hospital Policlinico Rodolico San Marco, Catania, Italy
| | - Dario Lipari
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Ignazio Arrigo
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Elena Galia
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Maria Rita Tricoli
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
| | - Maddalena Calvo
- Department of Biomedical and Biotechnological Sciences, University Hospital Policlinico Rodolico San Marco, Catania, Italy
| | - Claudia Niccolai
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Fabio Morecchiato
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Errico
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, University Hospital Policlinico Rodolico San Marco, Catania, Italy
| | - Rossana Cavallo
- University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy
- Microbiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maria Rosaria Catania
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Simone Ambretti
- Unit of Microbiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Annalisa Pantosti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Anna Teresa Palamara
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Michela Sabbatucci
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
- Directorate General for Health Prevention, Ministry of Health, Rome, Italy
| | - Nicola Serra
- Department of Public Health, University Hospital Federico II, Naples, Italy
| | - Anna Giammanco
- Department of Health Promotion, Maternal and Child Health, Internal Medicine and Medical Specialies “G. D’Alessandro”, University of Palermo, Palermo, Italy
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De Vita E, De Angelis L, Arzilli G, Baglivo F, Barnini S, Vecchione A, Baggiani A, Rizzo C, Porretta AD. Investigating Resistance to Carbapenems in Enterobacterales: A Descriptive Epidemiological Study of 2021 Screening in an Italian Teaching Hospital. Pathogens 2023; 12:1140. [PMID: 37764948 PMCID: PMC10535761 DOI: 10.3390/pathogens12091140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Antimicrobial resistance (AMR) presents a growing threat to global healthcare. This descriptive epidemiological study investigates the prevalence and characteristics of Enterobacterales with AMR factors in a tertiary teaching hospital in Italy over the course of the year 2021. In 2021, the prevalence of colonisation by Enterobacterales with AMR factors in patients was 1.08%. During the observation period, a total of 8834 rectal swabs were performed, with 1453 testing positive. A total of 5639 rectal swabs were performed according to a hospital procedure for the active screening of MDRO colonisation at the time of admission. Of these, 679 were positive for microorganisms under surveillance, and 74 patients were colonised with Enterobacterales, predominantly Klebsiella pneumoniae and Escherichia coli. Antibiotic resistance factors were observed in 61 of these 74 patients (82.43%) of these patients, with NDM and KPC being the most frequent resistance factors. A statistically significant trend in positive swabs was observed across different ward categories (surgery, ICUs, and medical wards). Regarding specific trends, the rate of positive admission screening in medical and surgical wards was higher than in ICU wards. The results highlight the ease with which Enterobacterales develops resistance across different ward categories. The findings underscore the need for adjusted screening protocols and tailored infection prevention strategies in various care settings.
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Affiliation(s)
- Erica De Vita
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
| | - Luigi De Angelis
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
| | - Guglielmo Arzilli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
| | - Francesco Baglivo
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
| | - Simona Barnini
- Microbiology Unit, University Hospital of Pisa, 56124 Pisa, Italy; (S.B.); (A.V.)
| | - Alessandra Vecchione
- Microbiology Unit, University Hospital of Pisa, 56124 Pisa, Italy; (S.B.); (A.V.)
| | - Angelo Baggiani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
- University Hospital of Pisa, 56123 Pisa, Italy
| | - Caterina Rizzo
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
| | - Andrea Davide Porretta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56123 Pisa, Italy; (E.D.V.); (L.D.A.); (F.B.); (A.B.); (C.R.); (A.D.P.)
- University Hospital of Pisa, 56123 Pisa, Italy
| | - Teams AID
- University Hospital of Pisa, 56123 Pisa, Italy
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7
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Effects of screening strategies to detect carbapenem-resistant gram-negative bacteria: A systematic review. Am J Infect Control 2022; 50:1381-1388. [PMID: 35227794 DOI: 10.1016/j.ajic.2022.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE This systematic review aims to summarize the evidence on the effects of screening strategies to detect carbapenem-resistant gram-negative bacteria (Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa). METHODS Eligible studies were randomized trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. We conducted searches in CENTRAL, PUBMED, Embase, Epistemonikos, and in multiple databases available in the Virtual Health Library (LILACS, Scielo, WHO IBECS, and PAHO IBECS). All the searches covered the period until 4 June 2021. No date or language restrictions were applied. Two reviewers independently evaluated potentially eligible studies according to predefined selection criteria, and extracted data on study characteristics, methods, outcomes, and risk of bias, using a predesigned standardized form. When possible, we intended to conduct meta-analyses using a random-effect model. We assessed the certainty of the evidence (CoE) and summarized the results using the GRADE approach. RESULTS Our search strategy yielded 57,451 references. No randomized trials were identified. Sixteen studies (one controlled before-after study and 15 interrupted time series) met our inclusion criteria and were included in the review. Most studies were conducted in tertiary care general hospitals from the United States, Europe, and Asia. Eleven studies included adult patients hospitalized in general wards and intensive care units, one was carried out in a neonatal intensive care unit, two in hematology or oncology units, and one in a solid organ transplantation department. Eleven studies were conducted in the setting of an outbreak. Regarding the detection strategy used, all studies included screening strategies for high-risk patients at the moment of admission and 7 studies reported a contact surveillance strategy. Most studies were conducted in settings where infection prevention and control measures were concomitantly installed or reinforced. Data were not suitable for meta-analysis, so the results were presented as a narrative synthesis. Most studies showed a decline in the prevalence of both infection and colonization rates after the implementation of a policy of active surveillance, but the CoE is low. Screening strategies may result in little to no difference in the risk of all-cause mortality and the length of hospital stay. CONCLUSIONS Existing evidence may favor the use of surveillance culture to carbapenem-resistant gram-negative bacteria, but its quality is poor, so solid conclusions cannot be drawn. Well-conducted randomized trials or high-quality quasi-experimental studies are needed to improve the certainty of the existing evidence. These studies should assess the effect of the addition of screening strategies as a single intervention and measure clinically important outcomes such as infection, length of hospital stay, and mortality.
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8
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Carrara E, Sibani M, Barbato L, Mazzaferri F, Salerno ND, Conti M, Azzini AM, Dalbeni A, Pellizzari L, Fontana G, Di Francesco V, Bissoli L, Del Monte L, Zamboni M, Olivieri O, Minuz P, Maccacaro L, Ghirlanda G, Tacconelli E. How to 'SAVE' antibiotics: effectiveness and sustainability of a new model of antibiotic stewardship intervention in the internal medicine area. Int J Antimicrob Agents 2022; 60:106672. [PMID: 36103917 DOI: 10.1016/j.ijantimicag.2022.106672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period. METHODS The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model. RESULTS A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention. CONCLUSIONS The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.
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Affiliation(s)
- Elena Carrara
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.
| | - Marcella Sibani
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy; Infectious Diseases Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Lorenzo Barbato
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Michela Conti
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Anna Maria Azzini
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Andrea Dalbeni
- Department of Medicine, General Medicine C Unit & Liver Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Luca Pellizzari
- Geriatric Unit A, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giorgia Fontana
- Geriatric Unit A, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Luisa Bissoli
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Letizia Del Monte
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Mauro Zamboni
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Oliviero Olivieri
- Medicina Interna ad Indirizzo Immunoematologico ed Emocoagulativo, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Pietro Minuz
- Department of Medicine, Section of General Medicine and Hypertension, University of Verona, Verona, Italy
| | - Laura Maccacaro
- Unit of Microbiology and Virology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanna Ghirlanda
- Medical Direction, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
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9
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Keshavarzi F. Practical Concerns about the Metrics and Methods of Financial Outcome Measurement in Antimicrobial Stewardship Programs: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:394-405. [PMID: 36117584 PMCID: PMC9445868 DOI: 10.30476/ijms.2021.92213.2343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/23/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022]
Abstract
Emerging pathogens in the meantime of paucity of new antibiotics discovery, put antimicrobial stewardship in the center of attention, to preserve the existing antimicrobial effect. Implementation of antimicrobial stewardship programs, however, needs approval from healthcare system managers. The approval process can be enhanced, when the beneficial effects of stewardship programs are supported by both clinical and financial evidence. Focusing on the financial outcome evaluation, the practitioners who run the stewardship programs, may choose certain methods and metrics, depending on the clinical setting scale and type, available human resources, and budget. The wise selection of the methods and metrics warrants a comprehensive insight of the existing methods and metrics, deployed by typically published works that set good examples to follow. This review is an attempt to provide such an insight along with typical relevant examples for each metric and method.
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Affiliation(s)
- Fazlollah Keshavarzi
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
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10
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Giufrè M, Errico G, Monaco M, Del Grosso M, Sabbatucci M, Pantosti A, Cerquetti M, Pagnotta M, Marra M, Carollo M, Rossini A, Fogato E, Cesana E, Gentiloni Silverj F, Zabzuni D, Tinelli M. Whole Genome Sequencing and Molecular Analysis of Carbapenemase-Producing Escherichia coli from Intestinal Carriage in Elderly Inpatients. Microorganisms 2022; 10:microorganisms10081561. [PMID: 36013979 PMCID: PMC9413394 DOI: 10.3390/microorganisms10081561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 01/27/2023] Open
Abstract
The spread of carbapenemase-producing (CP) Enterobacterales is currently a worldwide concern, especially in the elderly. Twelve CP-E. coli isolated from rectal swabs of colonized inpatients aged ≥65 years from four hospitals in two Italian cities (Milan and Rome) were analyzed by whole genome sequencing (WGS) to obtain multi-locus sequence typing (MLST), identification of carbapenemase-encoding genes, resistome, plasmid content, and virulence genes. MLST analysis showed the presence of 10 unrelated lineages: ST410 (three isolates from three different hospitals in two cities) and ST12, ST38, ST69, ST95, ST131, ST189, ST648, ST1288, and ST1598 (one isolate each). Most isolates (9/12, 75%) contained a serine-β-lactamase gene (5 blaKPC-3, 2 blaKPC-2, and 2 blaOXA-181), while three isolates harbored a metallo-β-lactamase gene (two blaNDM-5 and one blaVIM-1). In most CP-E. coli, the presence of more than one plasmid was observed, with the predominance of IncF. Several virulence genes were detected. All isolates contained genes enhancing the bacterial fitness, such as gad and terC, and all isolates but one, fimH, encoding type 1 fimbriae. In conclusion, CP-E. coli clones colonizing elderly patients showed heterogeneous genetic backgrounds. We recommend strict surveillance to monitor and prevent the spread of successful, high-risk clones in healthcare settings.
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Affiliation(s)
- Maria Giufrè
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
- Correspondence:
| | - Giulia Errico
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Monica Monaco
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Maria Del Grosso
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Michela Sabbatucci
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
- Ministry of Health, Directorate General Health Prevention, Communicable Diseases and International Prophylaxis, 00144 Rome, Italy
| | - Annalisa Pantosti
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Marina Cerquetti
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Michela Pagnotta
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (G.E.); (M.M.); (M.D.G.); (M.S.); (A.P.); (M.C.); (M.P.)
| | - Manuela Marra
- Core Facilities Technical-Scientific Service (FAST), Istituto Superiore di Sanità, 00161 Rome, Italy; (M.M.); (M.C.)
| | - Maria Carollo
- Core Facilities Technical-Scientific Service (FAST), Istituto Superiore di Sanità, 00161 Rome, Italy; (M.M.); (M.C.)
| | | | - Elena Fogato
- Golgi-Redaelli Geriatric Institute, 20146 Milan, Italy;
| | - Elisabetta Cesana
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy; (E.C.); (D.Z.); (M.T.)
| | | | - Dorjan Zabzuni
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy; (E.C.); (D.Z.); (M.T.)
| | - Marco Tinelli
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy; (E.C.); (D.Z.); (M.T.)
- Italian Society of Infectious and Tropical Diseases (SIMIT), 59100 Prato, Italy
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11
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A systematic review of the effectiveness of cohorting to reduce transmission of healthcare-associated C. difficile and multidrug-resistant organisms. Infect Control Hosp Epidemiol 2021; 41:691-709. [PMID: 32216852 DOI: 10.1017/ice.2020.45] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cohorting of patients and staff is a control strategy often used to prevent the spread of infection in healthcare institutions. However, a comprehensive evaluation of cohorting as a prevention approach is lacking. METHODS We performed a systematic review of studies that used cohorting as part of an infection control strategy to reduce hospital-acquired infections. We included studies published between 1966 and November 30, 2019, on adult populations hospitalized in acute-care hospitals. RESULTS In total, 87 studies met inclusion criteria. Study types were quasi-experimental "before and after" (n = 35), retrospective (n = 49), and prospective (n = 3). Case-control analysis was performed in 7 studies. Cohorting was performed with other infection control strategies in the setting of methicillin-resistant Staphylococcus aureus (MRSA, n = 22), Clostridioides difficile infection (CDI, n = 6), vancomycin-resistant Enterococcus (VRE, n = 17), carbapenem-resistant Enterobacteriaceae infections (CRE, n = 22), A. baumannii (n = 15), and other gram-negative infections (n = 5). Cohorting was performed either simultaneously (56 of 87, 64.4%) or in phases (31 of 87, 35.6%) to help contain transmission. In 60 studies, both patients and staff were cohorted. Most studies (77 of 87, 88.5%) showed a decline in infection or colonization rates after a multifaceted approach that included cohorting as part of the intervention bundle. Hand hygiene compliance improved in approximately half of the studies (8 of 15) during the respective intervention. CONCLUSION Cohorting of staff, patients, or both is a frequently used and reasonable component of an enhanced infection control strategy. However, determining the effectiveness of cohorting as a strategy to reduce transmission of MDRO and C. difficile infections is difficult, particularly in endemic situations.
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12
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Chuah CH, Gani Y, Sim B, Chidambaram SK. Risk factors of carbapenem-resistant Enterobacteriaceae infection and colonisation: a Malaysian tertiary care hospital based case-control study. J R Coll Physicians Edinb 2021; 51:24-30. [PMID: 33877130 DOI: 10.4997/jrcpe.2021.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) infection has become a major challenge to clinicians. The aim of this study is to identify the risk factors of acquiring CRE to guide more targeted screening for hospital admissions. METHODS This is a retrospective case-control study (ratio 1:1) where a patient with CRE infection or colonisation was matched with a control. The control was an individual who tested negative for CRE but was a close contact of a patient testing positive and was admitted at the same time and place. Univariate and multivariate statistical analyses were done. RESULTS The study included 154 patients. The majority of the CRE was Klebsiella species (83%). From univariate analysis, the significant risk factors were having a history of indwelling devices (OR: 2.791; 95% CI: 1.384-5.629), concomitant other MDRO (OR: 2.556; 95% CI: 1.144-5.707) and hospitalisation for more than three weeks (OR: 2.331; 95% CI: 1.163-4.673). Multivariate analysis showed that being unable to ambulate on admission (adjusted OR: 2.345; 95% CI: 1.170-4.699) and antibiotic exposure (adjusted OR: 3.515; 95% CI: 1.377-8.972) were independent predictors. The in-hospital mortality rate of CRE infection was high (64.5%). CRE acquisition resulted in prolonged hospitalisation (median=35 days; P<0.001). CONCLUSION CRE infection results in high morbidity and mortality. On top of the common risk factors, patients with mobility restriction, prior antibiotic exposures and hospitalisation for more than three weeks should be prioritised in the screening strategy to control the spread of CRE.
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Affiliation(s)
- Chuan Huan Chuah
- Department of Internal Medicine, Sungai Buloh Hospital, Jalan Hospital, Selangor, Malaysia,
| | - Yasmin Gani
- Department of Internal Medicine, Sungai Buloh Hospital, Ministry of Health Malaysia, Selangor, Malaysia
| | - Benedict Sim
- Department of Internal Medicine, Sungai Buloh Hospital, Ministry of Health Malaysia, Selangor, Malaysia
| | - Suresh Kumar Chidambaram
- Department of Internal Medicine, Sungai Buloh Hospital, Ministry of Health Malaysia, Selangor, Malaysia
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13
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Dai Y, Meng T, Wang X, Tang B, Wang F, Du Y, Qiu Y, Liu J, Tan R, Qu H. Validation and Extrapolation of a Multimodal Infection Prevention and Control Intervention on Carbapenem-Resistant Klebsiella pneumoniae in an Epidemic Region: A Historical Control Quasi-Experimental Study. Front Med (Lausanne) 2021; 8:692813. [PMID: 34307419 PMCID: PMC8292674 DOI: 10.3389/fmed.2021.692813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To verify the effects of comprehensive infection prevention and control (IPC) interventions for the prevention of the cross-transmission of carbapenem-resistant Klebsiella pneumoniae (CRKP) within intensive care units (ICUs) in an epidemic region. Methods: A historical control, quasi-experimental design was performed. The study was conducted between January 2017 and December 2019, following the implementation of a multimodal IPC bundle. The baseline period was established from January 2013 to June 2013, when only basic IPC measures were applied. Results: A total of 748 patients were enrolled during the entire study. The incidence of ICU-acquired CRKP colonization/infection was 1.16 per 1,000 patient-days during the intervention period, compared with 10.19 per 1,000 patient-days during the baseline period (p = 0.002). The slope of the monthly incidence of CRKP at admission showed an increasing trend (p = 0.03). The incidence of ICU-acquired catheter-related bloodstream infections caused by CRKP decreased from 2.54 to 0.96 per 1,000 central-line-days (p = 0.08). Compliance with contact precautions and terminal room disinfection improved during the intervention period. All environmental surface culture samples acquired after terminal room disinfection were negative for CRKP. Conclusion: Our findings suggest that in epidemic settings, multimodal IPC intervention strategies and consistent monitoring of compliance, may limit the spread of CRKP in ICUs.
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Affiliation(s)
- Yunqi Dai
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tianjiao Meng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoli Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Tang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ying Du
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuzhen Qiu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruoming Tan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hongping Qu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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14
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Carrara E, Conti M, Meschiari M, Mussini C. The role of antimicrobial stewardship in preventing KPC-producing Klebsiella pneumoniae. J Antimicrob Chemother 2021; 76:i12-i18. [PMID: 33534879 DOI: 10.1093/jac/dkaa493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Antimicrobial stewardship programmes are widely considered to be a core component of the response to the antimicrobial resistance threat. However, a positive impact of these interventions in terms of microbiological outcomes remains difficult to demonstrate, especially when focusing on specific resistant phenotypes. The first part of this review aims to explore the complex relationship between antibiotic exposure and resistance development in KPC-producing Klebsiella pneumoniae. In the second part we aim to summarize published examples of antimicrobial stewardship interventions intended to impact on the epidemiology of KPC-producing K. pneumoniae. For this purpose, a literature search was performed and seven studies were included in the review. Both restrictive and non-restrictive interventions were associated with an overall reduction in antibiotic consumption, and a decrease in carbapenem resistance rates was observed in five studies. The overall quality of the evidence was low, mainly due to the poor reporting of microbiological outcomes, lack of a control group and suboptimal study design. Although the link between antibiotic use and resistance development is supported by strong evidence, demonstrating the impact of antimicrobial stewardship interventions on microbiological outcomes remains difficult. Studies with adequate design and appropriate outcome measures are needed to further promote antimicrobial stewardship and elucidate which interventions are more successful for controlling the spread of KPC-producing K. pneumoniae.
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Affiliation(s)
- Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Michela Conti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
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Vargas JM, Moreno Mochi MP, López CG, Alarcón JA, Acosta N, Soria K, Nuñez JM, Villafañe S, Ramacciotti J, Del Campo R, Jure MA. [Impact of an active surveillance program and infection control measures on the incidence of carbapenem-resistant Gram-negative bacilli in an intensive care unit]. Rev Argent Microbiol 2021; 54:134-142. [PMID: 34088536 DOI: 10.1016/j.ram.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 03/11/2021] [Accepted: 03/28/2021] [Indexed: 11/30/2022] Open
Abstract
Hospital-acquired infections caused by carbapenem-resistant Gram-negative bacteria (CRGNB) have been increasingly reported worldwide and are associated with high rates of mortality especially in intensive care units(ICUs). Early identification through rectal surveillance cultures and implementation of infection control measures(ICM) including contact precautions, staff education on cleaning and hand hygiene may reduce the spread of these microorganisms. The aim of this work was to assess the impact of enhanced ICM on CRGNB colonization and to describe the molecular epidemiology of these bacteria in a polyvalent ICU in a tertiary level hospital. A prospective study including audits and active surveillance culture program, with molecular characterization, was conducted before and after the implementation of prevention programs and infection control measures. Microbiological screening was performed in chromogenic media; PCR targeting β-lactamases genes (blaKPC, blaNDM, blaVIM and blaOXA-48, blaSHV and blaCTX-M), molecular typing by PFGE; and MLST in K. pneumoniae were performed. CRGNB colonization was reduced from 16.92% to 9.67% upon implementing the infection control measures. In K. pneumoniae the most frequent carbapenemase type was KPC-2 associated with SHV-2 and CTX-M-15, and was disseminated in various STs (ST17, ST13, ST2256, ST353); there was no persistence of particular clones and virulence factors showed no association with hypervirulence. IMP-1 carbapenemase predominated in A. baumannii and the PFGE analysis individualized 3 clusters, assuming that the dissemination in the ICU was clonal. The early detection of patients colonized with CRBGN by using epidemiological surveillance cultures and the implementation of prophylactic measures are key to reducing the incidence of these microorganisms.
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Affiliation(s)
- Juan Martín Vargas
- Laboratorio de Bacteriología Certificado, Cátedra de Bacteriología, Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina.
| | - María Paula Moreno Mochi
- Laboratorio de Bacteriología Certificado, Cátedra de Bacteriología, Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina
| | - Carolina Graciela López
- Laboratorio de Bacteriología Certificado, Cátedra de Bacteriología, Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina
| | - Janet Alejandra Alarcón
- Laboratorio de Bacteriología Certificado, Cátedra de Bacteriología, Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina
| | - Nancy Acosta
- Unidad de cuidados intensivos 1 (UCI1), Hospital Ángel Cruz Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Karina Soria
- Departamento de Infectología, Hospital Ángel Cruz Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Juan Manuel Nuñez
- Departamento de Infectología, Hospital Ángel Cruz Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Sandra Villafañe
- Departamento de Infectología, Hospital Ángel Cruz Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Jorge Ramacciotti
- Unidad de cuidados intensivos 1 (UCI1), Hospital Ángel Cruz Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Rosa Del Campo
- Servicio de Microbiología, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, España
| | - María Angela Jure
- Laboratorio de Bacteriología Certificado, Cátedra de Bacteriología, Facultad de Bioquímica, Química y Farmacia, Universidad Nacional de Tucumán, San Miguel de Tucumán, Tucumán, Argentina
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16
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Linking infection control to clinical management of infections to overcome antimicrobial resistance. J Hosp Infect 2021; 114:1-9. [PMID: 33965455 DOI: 10.1016/j.jhin.2021.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
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17
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Carbapenem-resistant bacteria in an intensive care unit during the coronavirus disease 2019 (COVID-19) pandemic: A multicenter before-and-after cross-sectional study. Infect Control Hosp Epidemiol 2021; 43:461-466. [PMID: 33858547 PMCID: PMC8365044 DOI: 10.1017/ice.2021.144] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To assess the incidence of colonization and infection with carbapenemase-producing Enterobacteriaceae (CPE) and carbapenem-resistant Acinetobacter baumannii (CR-Ab) in the ICUs of our city hospitals before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: We conducted a multicenter, before-and-after, cross-sectional study to compare the rates of colonization and infection with CPE and/or CR-Ab in 2 study periods, period 1 (January–April 2019) and period 2 (January–April 2020). Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of weekly colonization and infection rates for each period were compared for the 2 study periods using Poisson regression. Weekly trends in the incidence of colonization or infection for each study period were summarized using local weighted (Loess) regression. Results: We detected no significant change in either IRR and weekly trend in CPE colonization and infection during the 2 study periods. A shift from KPC to other CPE mechanisms (OXA-48 and VIM) was observed during period 2. Compared to period 1, during period 2 the IRR of colonization and infection with CR-Ab increased 7.5- and 5.5-fold, respectively. Genome sequencing showed that all CR-Ab strains belonged to the CC92/IC2 clonal lineage. Clinical strains clustered closely into a single monophyletic group in 1 of the 3 centers, whereas they segregated in 2 different clusters in the other 2 centers, which strongly indicates horizontal transmission. Conclusions: Our findings indicate the need to conduct infection control activities targeted against the spread of antimicrobial resistance between and within hospitals during the COVID-19 pandemic, and if necessary, remodulating them according to the new organizational structures imposed by the pandemic.
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Kasatpibal N, Chittawatanarat K, Nunngam N, Kampeerapanya D, Duangsoy N, Rachakom C, Soison U, Apisarnthanarak A. Impact of multimodal strategies to reduce multidrug-resistant organisms in surgical intensive care units: Knowledge, practices and transmission: A quasi-experimental study. Nurs Open 2021; 8:1937-1946. [PMID: 33760380 PMCID: PMC8186694 DOI: 10.1002/nop2.864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 12/30/2022] Open
Abstract
Aim This study examined the effects of multimodal strategies on knowledge and practices in preventing multidrug‐resistant organism (MDRO) transmission among healthcare personnel (HCP), and to investigate MDRO transmission in two surgical intensive care units (SICUs). Design A quasi‐experimental study with a one‐group pretest–posttest design. Methods We recruited 62 HCP. Data were collected during 2017–2019. Multimodal strategies, including training, educational and reminder posters, an educational YouTube channel, champions and feedback, were used to enhance knowledge and practices. Data were analysed using Wilcoxon signed‐rank test and chi‐square test. Results After the intervention, median knowledge scores increased from 16.0 to 17.0 (p = .001), and overall correct MDRO prevention practices increased from 76.6% to 94.0% (p < .001). The MDRO transmission rate decreased from 25% to 0% (p < .001). Conclusion The findings indicate that multimodal strategies could enhance knowledge and practices for preventing MDRO transmission among HCP and could reduce the MDRO transmission rate in SICUs.
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Affiliation(s)
- Nongyao Kasatpibal
- Division of Nursing Science, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.,Epidemiology Research Center of Infectious Disease (ERCID), Chiang Mai University, Chiang Mai, Thailand
| | | | - Nantana Nunngam
- Infection Control Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Daranee Kampeerapanya
- Surgical Critical Care Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Nongnut Duangsoy
- Surgical Intensive Care Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Chanban Rachakom
- Surgical Critical Care Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Ubonrat Soison
- Surgical Critical Care Unit, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
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Initial impact of a national programme to contain the spread of carbapenemase-producing Enterobacterales in Ireland. J Hosp Infect 2021; 109:107-114. [DOI: 10.1016/j.jhin.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/20/2022]
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Cortés JA, Leal AL, Muñetón López G, Bravo-Ojeda JS, Nócua-Báez LC, Avila V, Silva E, Álvarez-Moreno CA, Espitia P, Gualtero SM, Valderrama SL, Guevara FO, Esparza G, Saavedra CH, Díaz JA, Valderrama-Ríos MC. Guía de práctica clínica para la tamización de pacientes con riesgo de colonización por Enterobacterales productores de carbapenemasas y el manejo de infecciones causadas por estas bacterias. REVISTA DE LA FACULTAD DE MEDICINA 2021. [DOI: 10.15446/revfacmed.v69n3.90140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Las infecciones por Enterobacterales productores de carbapenemasas (EPC) han aumentado en los últimos años. Colombia se ha convertido en un país endémico para este grupo de microorganismos y las infecciones que causan tienen un impacto importante en términos de morbilidad y mortalidad. La identificación temprana de los portadores de EPC que ingresan como pacientes a las instituciones de salud es necesaria para implementar medidas de aislamiento y control de infecciones adecuadas que limiten la diseminación de este tipo de microorganismos en los hospitales. Además, el tratamiento de estas infecciones es difícil debido a las limitadas alternativas terapéuticas disponibles y la escasez de estudios que demuestren su efectividad en este escenario.
Por lo anterior, el objetivo del presente trabajo es desarrollar una guía de práctica clínica (GPC) para la tamización de pacientes con riesgo de colonización por EPC y para el manejo de pacientes con infecciones, ya sea sospechadas o confirmadas, causadas por este tipo de bacterias, mediante un proceso de adaptación de GPC basado en la metodología ADAPTE. Con este propósito en mente, se hacen recomendaciones informadas en evidencia para realizar la tamización y oportuna identificación de portadores de EPC admitidos en instituciones hospitalarias, así como para el adecuado manejo farmacológico de las infecciones por EPC en este escenario.
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Sibani M, Mazzaferri F, Carrara E, Pezzani MD, Arieti F, Göpel S, Paul M, Tacconelli E, Mutters NT, Voss A. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in long-term care facilities-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2020; 75:ii33-ii41. [PMID: 33280047 PMCID: PMC7719406 DOI: 10.1093/jac/dkaa427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In long-term care facilities (LTCFs) residents often receive inappropriate antibiotic treatment and infection prevention and control practices are frequently inadequate, thus favouring acquisition of MDR organisms. There is increasing evidence in the literature describing antimicrobial stewardship (AMS) activities in LTCFs, but practical guidance on how surveillance data should be linked with AMS activities in this setting is lacking. To bridge this gap, the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks joined their efforts to provide practical guidance for linking surveillance data with AMS activities. MATERIALS AND METHODS Considering the three main topics [AMS leadership and accountability, antimicrobial usage (AMU) and AMS, and antimicrobial resistance (AMR) and AMS], a literature review was performed and a list of target actions was developed. Consensus on target actions was reached through a RAND-modified Delphi process involving 40 experts from 18 countries and different professional backgrounds adopting a One Health approach. RESULTS From the 25 documents identified, 25 target actions were retrieved and proposed for expert evaluation. The consensus process produced a practical checklist including 23 target actions, differentiating between essential and desirable targets according to clinical relevance and feasibility. Flexible proposals for AMS team composition and leadership were provided, with a strong emphasis on the need for well-defined and adequately supported roles and responsibilities. Specific antimicrobial classes, AMU metrics, pathogens and resistance patterns to be monitored are addressed. Effective reporting strategies are described. CONCLUSIONS The proposed checklist represents a practical tool to support local AMS teams across a wide range of care delivery organization and availability of resources.
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Affiliation(s)
- Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Mical Paul
- Diseases Institute, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Al Fadhli AH, Jamal WY, Rotimi VO. Prevalence of carbapenem-resistant Enterobacteriaceae and emergence of high rectal colonization rates of blaOXA-181-positive isolates in patients admitted to two major hospital intensive care units in Kuwait. PLoS One 2020; 15:e0241971. [PMID: 33201906 PMCID: PMC7671514 DOI: 10.1371/journal.pone.0241971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/25/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Fecal colonization by carbapenem-resistant Enterobacteriaceae (CRE) can be the main reservoir for transmission of these resistant organisms especially in the Intensive Care Units (ICUs). AIM This study was conducted to evaluate the rate of rectal carriage and molecular characterization of CRE in patients hospitalized in the ICUs of 2 major hospitals (Adan and Mubarak Al Kabeer Hospitals) in Kuwait. MATERIALS AND METHODS Rectal swabs were collected from all patients at admission, 48 h after admission and once weekly from April 2017- March 2018. Initial CRE screening was carried out on MacConkey agar on which meropenem disc 10μg was placed. Identification of isolates was by API 20E. Susceptibility testing was performed using the E-test method. Polymerase chain reaction (PCR) was used to detect the carbapenemase-encoding genes. Clonal relationship was investigated by pulsed-field electrophoresis (PFGE). Genes of blaOXA-181 and blaNDM-5-carrying plasmids were detected in some strains. RESULTS A total of 590 patients were recruited into the study. Of these, 58 were positive for CRE, giving a prevalence of 9.8%; 25/320 (7.8%) in Adan and 33/270 (12.2%) in Mubarak Al Kabeer Hospitals. All isolates were resistant to multiple antibiotics. Resistance rates to colistin and tigecycline were 17% and 83%, respectively. Single genes of blaOXA-181 were detected in isolates from 38 (65.5%) out of 58 patients and in 5 patients colonized by blaOXA-48-positive CRE. A combination of 2 genes was detected in 12 isolates; 5 blaKPC-2 and blaOXA-181, 4 blaVIM-1 and blaOXA-181, and 3 blaNDM-5 and blaOXA-181. PFGE showed an overall level of similarity of 38%. Southern hybridization studies localized the blaOXA-181 and blaNDM-5 genes to a large plasmid of 200kb in 3 K. pneumoniae isolates and a small plasmid of 80kb in 2 E. coli isolates, respectively. CONCLUSION The prevalence of CRE colonization in the 2 hospital ICUs was relatively high and the emergence of blaOXA-181-mediated CRE is a cause for concern as there is the possibility of rapid horizontal spread among hospital patients in Kuwait. Active surveillance of CRE in the ICUs is highly recommended to stem its spread.
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Affiliation(s)
- Amani H. Al Fadhli
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Wafaa Y. Jamal
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
- * E-mail:
| | - Vincent O. Rotimi
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
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Spyridopoulou K, Psichogiou M, Sypsa V, Miriagou V, Karapanou A, Hadjihannas L, Tzouvelekis L, Daikos GL. Containing Carbapenemase-producing Klebsiella pneumoniae in an endemic setting. Antimicrob Resist Infect Control 2020; 9:102. [PMID: 32631456 PMCID: PMC7339575 DOI: 10.1186/s13756-020-00766-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/23/2020] [Indexed: 12/02/2022] Open
Abstract
Background Carbapenemase-producing K. pneumoniae (CP-Kp) has been established as important nosocomial pathogen in most tertiary care hospitals in Greece. The aim of the present study was to examine the impact of an enhanced infection control program on the containment of CP-Kp in a haematology unit where the incidence of CP-Kp infections was high. Methods The study was conducted from June 2011 to December 2014 in a haematology unit of a tertiary-care 500-bed hospital located in Athens, Greece. A bundled intervention (active surveillance cultures, separation of carriers from non-carriers, assignment of dedicated nursing staff, contact precautions, environmental cleaning, and promotion of hand hygiene) was tested whether would reduce colonization and infection caused by CP-Kp. Results A total of 2507 rectal swabs were obtained; 1199 upon admission from June 2011 to June 2013 and 1307 during hospitalization from June 2011 to December 2012. During intervention the admission prevalence of CP-Kp colonization (p < 0.001 for linear trend), the hospitalization prevalence (p = 0.001 for linear trend) and the incidence rate of CP-Kp colonization (p = 0.072 for linear trend) were declining. Application of segmented linear regression revealed that both the change in the level of CP-Kp BSI incidence rates (p = 0.001) as well as the difference between pre- and post-intervention slopes were statistically significant (p < 0.001). Conclusions A bundled intervention including active surveillance cultures on admission can attain maximum containment of CP-Kp colonization and infection in endemic acute healthcare settings.
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Affiliation(s)
- Kalliopi Spyridopoulou
- First Department of Medicine, Medical School, "Laiko" General Hospital, National and Kapodistrian University of Athens, 75, 11527, Athens, Greece
| | - Mina Psichogiou
- First Department of Medicine, Medical School, "Laiko" General Hospital, National and Kapodistrian University of Athens, 75, 11527, Athens, Greece
| | - Vana Sypsa
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vivi Miriagou
- Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece
| | - Amalia Karapanou
- First Department of Medicine, Medical School, "Laiko" General Hospital, National and Kapodistrian University of Athens, 75, 11527, Athens, Greece
| | - Linos Hadjihannas
- First Department of Medicine, Medical School, "Laiko" General Hospital, National and Kapodistrian University of Athens, 75, 11527, Athens, Greece
| | - Leonidas Tzouvelekis
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George L Daikos
- First Department of Medicine, Medical School, "Laiko" General Hospital, National and Kapodistrian University of Athens, 75, 11527, Athens, Greece.
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Zhu J, Li Q, Li X, Kang J, Song Y, Song J, Yin D, Duan J. Successful control of the first carbapenem-resistant Klebsiella pneumoniae outbreak in a Chinese hospital 2017-2019. Antimicrob Resist Infect Control 2020; 9:91. [PMID: 32571431 PMCID: PMC7310137 DOI: 10.1186/s13756-020-00757-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background Carbapenem-resistant Klebsiella pneumoniae (CRKP) is considered as a serious global threat. CRKPs occurred only sporadically in the Second Hospital of Shanxi Medical University. Our study aimed to investigate and control the first outbreak of CRKP in our hospital occurred between October 2017 and August 2019. Methods The antimicrobial stewardship (AMS) workers have been implemented control measures properly. Clinical and epidemiological data were retrospectively collected from medical records. Carbapenemase genes were detected by modified carbapenem inactivation method (mCIM) test and the EDTA-modified carbapenem inactivation method (eCIM) test. Resistance genes were identified by polymerase chain reaction (PCR) and sequencing. Genetic relatedness was studied by multilocus sequence typing (MLST). Results During the outbreak, 31 patients were infected with CRKP isolates. 20 (64.5%) patients were infected with KPC-2 and/or NDM-1 producing K. pneumoniae. Mostly MLST-sequence types belonged to ST11 (21/31). The outbreak was two major K. pneumoniae clusters present in epidemiologically linked patients. Conclusions Setting up AMS workers is potentially a highly efficient strategy for the successful control of the outbreak. A multimodal and multidisciplinary infection control strategy proved to be crucial. The emergence of CRKP in our hospital emphasizes the importance of continuous monitoring of these isolates, which helps to limit the spread of CRKPs and improve the level of management.
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Affiliation(s)
- Jiaying Zhu
- Department of Pharmacy, school of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China.,Department of Pharmacy, Baotou Hospital of Traditional Mongolian and Chinese Medicine, Baotou, Inner Mongolia, People's Republic of China
| | - Qi Li
- Department of Pharmacy, school of Pharmacy, Shanxi Medical University, Taiyuan, Shanxi, People's Republic of China
| | - Xiaoxia Li
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China
| | - Jianbang Kang
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China
| | - Yan Song
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China
| | - Junli Song
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China
| | - Donghong Yin
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China
| | - Jinju Duan
- Department of Pharmacy, Second Hospital of Shanxi Medical University, No 382, Wuyi Road, Xinghualing District, Taiyuan, Shanxi, People's Republic of China.
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Vigário A, Gonçalves JA, Costa AR, Pinheiro G, Reis E, Oliveira JR. Implementation of an infection control program with emphasis on cohorting to patients with carbapenemase-producing Enterobacteriaceae. The experience of 2 years in a tertiary teaching hospital in northern Portugal. Porto Biomed J 2020; 5:e68. [PMID: 33299948 PMCID: PMC7722402 DOI: 10.1097/j.pbj.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/29/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The emergence of carbapenemase-producing Enterobacterales (CPE) represents a major public health threat. Our purpose was to evaluate a surveillance and cohorting program implemented in patients infected or carriers of CPE. METHODS A prospective registry of CPE carriers or infected patients was analyzed from October 2015 until December 2017. All inpatients presenting with CPE were included in a hospital cohort with dedicated healthcare staff and contact precaution measures. RESULTS A total of 480 patients were identified, of which 15.8% (n = 76) were infected. Men comprised 56.7% of the cohort (n = 272) and 69.2% (n = 332) were elderly. About 46.3% (n = 222) had a previous hospital admission and 81.7% (n = 392) had at least 1 antibiotic course in the previous 90 days. There was a decline in infected patients in 2017. Periodic and admission screenings accounted for 63% and 74% of cases in 2016 and 2017, with increased detection rate comparing with contact/investigation screenings. In 2017, significantly fewer patients were identified outside the admission/point of prevalence screening (P = .009). In 2017 the proportion of invasive carbapenem-resistant Klebsiella pneumoniae amongst CPE in our center was below the national average (2016: 13.3% vs 5.2%; 2017: 6.6% vs 8.6%). A reduction of the consumption of carbapenems was also observed in 2017. CONCLUSION The implementation of the program has increased the number of patients identified by the preventive method and stabilized the emergence of new CPE cases. Furthermore, the program cohort compared well with the national picture, with a lower number of infected patients and a lower proportion of carbapenem-resistant K pneumoniae in invasive specimens. These indicators reflect the added value of the CPE surveillance and cohorting program.
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Affiliation(s)
| | | | | | | | - Ernestina Reis
- Internal Medicine Department, Comissão de Controlo de Infeção e Resistência aos Antimicrobianos (CCIRA), Centro Hospitalar e Universitário do Porto, Porto, Protugal
| | - Júlio R Oliveira
- Internal Medicine Department, Comissão de Controlo de Infeção e Resistência aos Antimicrobianos (CCIRA), Centro Hospitalar e Universitário do Porto, Porto, Protugal
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Ben-David D, Masarwa S, Fallach N, Temkin E, Solter E, Carmeli Y, Schwaber MJ. Success of a National Intervention in Controlling Carbapenem-resistant Enterobacteriaceae in Israel's Long-term Care Facilities. Clin Infect Dis 2020; 68:964-971. [PMID: 29986007 DOI: 10.1093/cid/ciy572] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) are a major reservoir of carbapenem-resistant Enterobacteriaceae (CRE) in healthcare facilities, contributing to rapid regional dissemination of CRE. METHODS In 2008, The Israeli National Center for Infection Control (NCIC) initiated a coordinated, comprehensive intervention in Israel's LTCFs, encompassing approximately 25000 beds in over 300 institutions. The intervention included implementation of population-tailored contact precautions and early detection of carriers. The NCIC established a real-time repository of all CRE carriers and events of acquisition, supervised information exchange between healthcare facilities and directed intervention at the institutional level during local outbreaks. CRE incidence was determined based on detection of CRE, either during LTFC stay or on admission to another facility. Prevalence was determined by a series of 5 cross-sectional surveys commenced between 2008 and 2015. RESULTS From January 2009 through December 2015, 5265 patients acquired CRE in LTCFs. During the study period, incidence of acquisition declined in all facility types, to approximately 50% of the baseline (P < .001). The number of skilled nursing facilities and nursing homes experiencing ≥ 5 CRE acquisitions annually decreased from 35 to 11 during this period. The point prevalence of newly detected CRE carriage in post-acute care hospitals decreased from 12.3% in the survey commenced in 2008 to 0.8% in that begun in 2015 (P < .001). CONCLUSIONS A national, coordinated intervention resulted in a sustained decrease in CRE incidence and prevalence in LTCFs. These results support the assumption that centrally coordinated intervention is an essential public health tool in reducing CRE in healthcare facilities.
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Affiliation(s)
- Debby Ben-David
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Samira Masarwa
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Noga Fallach
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Elizabeth Temkin
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Ester Solter
- National Center for Infection Control, Israel Ministry of Health, Israel
| | - Yehuda Carmeli
- National Center for Infection Control, Israel Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Mitchell J Schwaber
- National Center for Infection Control, Israel Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
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Hassoun-Kheir N, Snitser O, Hussein K, Rabino G, Eluk O, Warman S, Aboalhega W, Geffen Y, Mendelson S, Kishony R, Paul M. Concordance between epidemiological evaluation of probability of transmission and whole genome sequence relatedness among hospitalized patients acquiring Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae. Clin Microbiol Infect 2020; 27:468.e1-468.e7. [PMID: 32360206 DOI: 10.1016/j.cmi.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/28/2020] [Accepted: 04/16/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to evaluate the concordance between epidemiologically determined transmission and genetic linkage of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp). METHODS We included consecutive KPC-Kp carriers between December 2016 and April 2017 in a hospital endemic for KPC-Kp. We assessed epidemiological relatedness between patients by prospective investigations by the infection control team. The probability of epidemiological relatedness was classified into four groups: no suspected transmission, low, moderate and high probability of transmission. Whole-genome sequencing of isolates was performed. Genetic linkage between KPC-Kp isolates was expressed by distance between isolates in single nucleotide polymorphisms (SNPs). We established an SNP cut-off defining a different strain based on the reconstructed phylogenetic tree. We compared the epidemiological and genetic linkage of all isolates from all patients. RESULTS The study included 25 KPC-Kp carriers with 49 isolates. SNP variance was available for 1129 crossed patient-isolate pairs. Genomic linkage, based on a cut-off of 80 SNPs to define related isolates, was found in 115/708 (16.2%) of isolates with no transmission suspected epidemiologically, 27/319 (8.5%) of low, 11/26 (42.3%) of moderate and 64/76 (84.2%) of high epidemiological transmission risk determination (p < 0.001 for trend). Similar results and significant trends were shown on sensitivity analyses using a lower SNP cut-off (six SNPs) and patient-isolate unique pairs, analysing the first isolate from each patient. CONCLUSIONS While significant concordance between epidemiological and genomic transmission patterns was found, epidemiological investigations of transmission are limited by the possibility of unidentified transmissions or over-estimation of associations. Genetic linkage analysis is an important aid to epidemiological transmission assessment.
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Affiliation(s)
- N Hassoun-Kheir
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel.
| | - O Snitser
- Technion - Israel Institute of Technology, Haifa, Israel
| | - K Hussein
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
| | - G Rabino
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel
| | - O Eluk
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel
| | - S Warman
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel
| | - W Aboalhega
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel
| | - Y Geffen
- Technion - Israel Institute of Technology, Haifa, Israel; Clinical Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - S Mendelson
- Clinical Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - R Kishony
- Technion - Israel Institute of Technology, Haifa, Israel
| | - M Paul
- Infectious Diseases and Infection-Control Unit, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
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Hilliquin D, Lomont A, Zahar JR. Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory? J Hosp Infect 2020; 105:S0195-6701(20)30197-3. [PMID: 32315668 DOI: 10.1016/j.jhin.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination. AIM/METHODS We conducted a narrative review of the literature and discussed the role of cohorting. FINDINGS CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated. CONCLUSION Local epidemiology and resources must be assessed before implementing cohorting.
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Affiliation(s)
- Delphine Hilliquin
- Unité d'hygiène et d'épidémiologie, Hôpital Édouard Herriot, GH Centre, Hospices civils de Lyon, France; Université Lyon 1 Claude Bernard, Lyon, France.
| | - Alexandra Lomont
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
| | - Jean-Ralph Zahar
- Service de Microbiologie Clinique, Unité de contrôle et prévention du risque infectieux, GH Paris Seine Saint-Denis, AP-HP, Bobigny, France; IAME, Inserm 1137, Université Sorbonne Paris Nord - Paris 13, France
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Yin L, He L, Miao J, Yang W, Wang X, Ma J, Wu N, Cao Y, Wang L, Lu G, Li L, Lu C, Hu J, Zhang L, Zhao B, Zhai X, Wang C. Actively surveillance and appropriate patients placements' contact isolation dramatically decreased Carbapenem-Resistant Enterobacteriaceae infection and colonization in pediatric patients in China. J Hosp Infect 2020; 105:S0195-6701(20)30130-4. [PMID: 32243954 DOI: 10.1016/j.jhin.2020.03.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/24/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND With the increasing use of carbapenems in clinic practice, carbapenem-resistant Enterobacteriaceae (CRE) has also increased, thus posing a significant threat to human health. AIM To assess the effects of CRE colonization active screening and various CRE patient placements implemented in decreasing CRE infection risk. METHODS CRE colonization screening and various CRE patient placements were performed across CRE high-risk departments (PICU, NICU, neonatal wards and hematology departments) between 2017 and 2018, respectively. FINDING In 2018, more than 80% neonatal CRE positive patients were isolated using single room or same room isolation, and more than 50% non-neonatal patients were, with no cohort placement. The CRE nosocomial infection incidences decreased from 1.96% to 0.63% in NICU, and from 0.57% to 0.30% in neonatal wards (all P<0.05) while no significant changes were found in the other departments. The CRE colonization incidence at different length hospital stay (LOS) decreased at 8-14days and >14days LOS in CRE high-risk departments (all P<0.05). In addition, 62.5% clinical strains, 66.7% screening strains, and 74.1% nosocomial infection strains were belonged to CC17 complex group in neonatal isolates; while, 56.6%, 47.5% and 100% strains mentioned above were belonged to CC11 complex group in non-neonatal isolates respectively. The predominant carbapenemase gene was blaNDM-1 (98%) in neonatal and blaKPC-2 (70%) in non-neonatal CR-KP stains. CONCLUSIONS Active CRE colonization surveillance and CRE positive patient propriety placement may decrease the CRE infection risk. Neonatal and non-neonatal CR-KP isolates showed different CRE molecular characteristics, which could further benefit CRE infection precaution and antibiotic therapy.
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Affiliation(s)
- Lijun Yin
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Leiyan He
- The Clinical Microbiology Laboratory, Children's Hospital of Fudan University, Shanghai, China
| | - Jin Miao
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Weiqing Yang
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaohua Wang
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Jian Ma
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Nana Wu
- Department of Nosocomial Infection Control, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of neonatal intensive care unit, Children's Hospital of Fudan University, Shanghai, China
| | - Laishuan Wang
- Department of Neonatal room, Children's Hospital of Fudan University, Shanghai, China
| | - Guoping Lu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Liling Li
- Department of Nursing Department, Children's Hospital of Fudan University, Shanghai, China
| | - Chunmei Lu
- Department of Neonatal room, Children's Hospital of Fudan University, Shanghai, China
| | - Jing Hu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Lei Zhang
- The Clinical Microbiology Laboratory, Children's Hospital of Fudan University, Shanghai, China
| | - Bing Zhao
- Shanghai Pudong Center for Disease Control and Prevention, Shanghai, China
| | - Xiaowen Zhai
- Department of Hematology, Children's Hospital of Fudan University, Shanghai, China.
| | - Chuanqing Wang
- Department of Nosocomial Infection Control and the Clinical Microbiology Laboratory, Children's Hospital of Fudan University, Shanghai, China.
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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Karampatakis T, Tsergouli K, Iosifidis E, Antachopoulos C, Volakli E, Karyoti A, Sdougka M, Tsakris A, Roilides E. Effects of an Active Surveillance Program and Enhanced Infection Control Measures on Carbapenem-Resistant Gram-Negative Bacterial Carriage and Infections in Pediatric Intensive Care. Microb Drug Resist 2019; 25:1347-1356. [DOI: 10.1089/mdr.2019.0061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Theodoros Karampatakis
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Katerina Tsergouli
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - Charalampos Antachopoulos
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - Eleni Volakli
- Pediatric Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - Angeliki Karyoti
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
- Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - Maria Sdougka
- Pediatric Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - Athanassios Tsakris
- Microbiology Department, National and Kapodistrian University School of Medicine, Athens, Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
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Ambretti S, Bassetti M, Clerici P, Petrosillo N, Tumietto F, Viale P, Rossolini GM. Screening for carriage of carbapenem-resistant Enterobacteriaceae in settings of high endemicity: a position paper from an Italian working group on CRE infections. Antimicrob Resist Infect Control 2019; 8:136. [PMID: 31423299 PMCID: PMC6693230 DOI: 10.1186/s13756-019-0591-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/31/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction A variety of national and international guidelines exist around the management of carbapenem resistant Enterobacteriaceae (CREs), but some of these are several years old and do not reflect current epidemiology and they also do not necessarily give pragmatic advice around active surveillance of CREs in countries with a high burden of cases and limited resources. This paper aims to provide a best practice position paper to guide active surveillance in a variety of scenarios in these settings, and discusses which patients should be screened, what methods could be used for screening, and how results might influence infection prevention interventions. Methods This paper was developed as a result of a series of meetings of expert opinion leaders representing the major infectious disease and infection prevention societies in Italy and having the endorsement of AMCLI (Italian Association of Clinical Microbiology) and SITA (Italian Society for Anti-infective Therapy). There was no attempt to undertake a full systematic review of the evidence, as it was felt that this was inadequate to inform a pragmatic view on the best way forward based on current epidemiology and infection rates. Key recommendations Key recommendations focus on the urgent need to promote measures to prevent transmission and infection, focusing on high risk patients and clinical areas, as well as outbreak situations. Active surveillance leading to appropriate infection prevention precautions plays a major role in this. Conclusions There are limited national or international guidelines giving pragmatic advice on the most appropriate measures for active surveillance and management of colonized patients in a high-burden setting such as Italy. While individual hospitals and regions will need to formulate their own policies based on local epidemiology, this position paper attempts to highlight current best practice in this area and provide pragmatic advice for clinicians, infection prevention staff, and healthcare managers.
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Affiliation(s)
- Simone Ambretti
- 1Unit of Clinical Microbiology, St Orsola-Malpighi University Hospital, Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Bassetti
- 2Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Pierangelo Clerici
- Microbiological Unit, Department of Laboratory Medicine and Diagnostics Biotecnology, Azienda Socio Sanitaria Territoriale Ovest Milanese, Via Giovanni Paolo II, 2025 Legnano, Mi Italy
| | - Nicola Petrosillo
- 4National Institute for Infectious Diseases "L. Spallanzani", IRCCS-, Rome, Italy
| | - Fabio Tumietto
- 5Infectious Diseases Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Pierluigi Viale
- 5Infectious Diseases Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Gian Maria Rossolini
- 6Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
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33
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Smibert O, Satlin MJ, Nellore A, Peleg AY. Carbapenem-Resistant Enterobacteriaceae in Solid Organ Transplantation: Management Principles. Curr Infect Dis Rep 2019; 21:26. [PMID: 31183574 DOI: 10.1007/s11908-019-0679-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as a worldwide problem. Given their degree of immunosuppression and the level of contact with the healthcare system, solid organ transplant (SOT) recipients are at a disproportionately higher risk of acquisition, colonization, and infection with CRE, and outcomes from infection tend to be worse compared to non-transplant patients. Therapeutic options are limited for CRE infections although several newer agents have recently been approved for use. How well these agents perform in the setting of immunosuppression and SOT is unclear. We sought to review the epidemiology of CRE in SOT and the management principles. RECENT FINDINGS CRE infections are becoming an increasing problem in SOT, and donor-derived infections present a challenge in the peri-transplant period. Newer treatments for CRE are emerging that are less toxic and potentially more effective than prior CRE-active agents, but supportive clinical data are limited. Newer beta-lactamase inhibitors have good activity against KPC carbapenemases, but they lack activity against metallo-beta-lactamases (e.g., NDM). Promising data is emerging with newer agents that have activity against most carbapenemases, but, again, clinical data is needed. Combination therapy in addition to optimal pharmacokinetic and pharmacodynamics may go some way to improve outcomes against these difficult-to-treat organisms. Other novel therapies that prevent the emergence of resistance (oral beta-lactamase inhibitors) and eradication of resistant Gram-negative colonization (fecal microbiota transplant) may eventually become part of a bundle approach to reduce CRE infections in the future. As in non-transplant patients, CRE infections in the transplant setting are challenging to treat and prevent. Infection prevention and control remains crucial to prevent widespread dissemination, and unique challenges exist with donor-derived CRE and how best to manage recipients in the peri-transplant period. Newer treatments are now in early-phase clinical studies, and in vitro activity data are supportive for several agents providing hope for improved outcomes with these typically difficult-to-treat and highly morbid infections in transplant recipients.
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Affiliation(s)
- Olivia Smibert
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia.,Transplant Infectious Disease and Compromised Host Program, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia. .,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.
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Giannella M, Pascale R, Gutiérrez-Gutiérrez B, Cano A, Viale P. The use of predictive scores in the management of patients with carbapenem-resistant Klebsiella pneumoniae infection. Expert Rev Anti Infect Ther 2019; 17:265-273. [PMID: 30876375 DOI: 10.1080/14787210.2019.1595590] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections are associated with high morbidity and mortality rates. A therapeutic approach based on the patient risk stratification could improve outcome and avoid antibiotic misuse. Areas covered: English literature search, from 2008 to 2018, was done using PubMed database. Risk factors for developing CR-KP infection in several settings were reviewed. Since, rectal carriage was a main risk factor for developing infection, we revised in deep clinical score to predict infection among colonized patients. Furthermore, we investigated overall and treatment-related risk factors for poor outcome in patients with CR-KP infection, in particular the carbapenem producing Enterobacteriacieae (CPE)-INCREMENT score. Finally, an algorithm, based on such scores, for the therapeutic management of patients with CR-KP colonization was commented. Expert opinion: The therapeutic approach analyzed in this review could help physicians to avoid antibiotic overuse as well as to start promptly with the most appropriate antibiotic regimen. However, it has to be validated in further studies, mainly among special population such as immunocompromised patients. The availability of new drugs, fast microbiology, and analysis of gut microbiome could significantly improve the management of CR-KP colonized and/or infected patients.
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Affiliation(s)
- Maddalena Giannella
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Renato Pascale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Belén Gutiérrez-Gutiérrez
- b Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS) and Department of Medicine , Universidad de Sevilla , Sevilla , Spain
| | - Angela Cano
- c Infectious Diseases Unit , Hospital Univesritario Reina Sofia-Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC)-Unversidad de Cordoba , Cordoba , Spain
| | - Pierluigi Viale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
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Tomczyk S, Zanichelli V, Grayson ML, Twyman A, Abbas M, Pires D, Allegranzi B, Harbarth S. Control of Carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa in Healthcare Facilities: A Systematic Review and Reanalysis of Quasi-experimental Studies. Clin Infect Dis 2019; 68:873-884. [PMID: 30475989 PMCID: PMC6389314 DOI: 10.1093/cid/ciy752] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 09/26/2018] [Indexed: 12/19/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) are a serious cause of healthcare-associated infections, although the evidence for their control remains uncertain. We conducted a systematic review and reanalysis to assess infection prevention and control (IPC) interventions on CRE-CRAB-CRPsA in inpatient healthcare facilities to inform World Health Organization guidelines. Six major databases and conference abstracts were searched. Before-and-after studies were reanalyzed as interrupted time series if possible. Effective practice and organization of care (EPOC) quality criteria were used. Seventy-six studies were identified, of which 17 (22%) were EPOC-compatible and interrupted time series analyses, assessing CRE (n = 11; 65%), CRAB (n = 5; 29%) and CRPsA (n = 3; 18%). IPC measures were often implemented using a multimodal approach (CRE: 10/11; CRAB: 4/5; CRPsA: 3/3). Among all CRE-CRAB-CRPsA EPOC studies, the most frequent intervention components included contact precautions (90%), active surveillance cultures (80%), monitoring, audit and feedback of measures (80%), patient isolation or cohorting (70%), hand hygiene (50%), and environmental cleaning (40%); nearly all studies with these interventions reported a significant reduction in slope and/or level. The quality of EPOC studies was very low to low.
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Affiliation(s)
- Sara Tomczyk
- Infection Prevention and Control Global Unit, Service Delivery and Safety Department, World Health Organization, Switzerland
- Institute of Global Health, University of Geneva, Switzerland
| | - Veronica Zanichelli
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - M Lindsay Grayson
- Infectious Diseases Department, Austin Health, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - Anthony Twyman
- Infection Prevention and Control Global Unit, Service Delivery and Safety Department, World Health Organization, Switzerland
| | - Mohamed Abbas
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Daniela Pires
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
- Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety Department, World Health Organization, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Switzerland
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The burden of colonization and infection by carbapenemase-producing Enterobacteriaceae in the neuro-rehabilitation setting: a prospective six-year experience. Infect Control Hosp Epidemiol 2019; 40:368-371. [PMID: 30767830 DOI: 10.1017/ice.2018.344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We describe the high burden of carbapenemase-producing Enterobacteriaceae (CPE) colonization and infection in a neuro-rehabilitation hospital in Italy over a 6-year period. Overall, 9.3% of patients were found to be CPE carriers on admission; the rates of CPE in-hospital acquisition and CPE-BSI were 9.2 and 2.9 cases per 10,000 patient days, respectively.
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37
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Moghnieh RA, Kanafani ZA, Tabaja HZ, Sharara SL, Awad LS, Kanj SS. Epidemiology of common resistant bacterial pathogens in the countries of the Arab League. THE LANCET. INFECTIOUS DISEASES 2018; 18:e379-e394. [PMID: 30292478 DOI: 10.1016/s1473-3099(18)30414-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 06/03/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
No uniformly organised collection of data regarding antimicrobial resistance has occurred in the countries of the Arab League. 19 countries of the Arab League have published data for antimicrobial susceptibility for the WHO priority organisms, and seven of 14 of these organisms are included in this Review (Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, Acinetobacter baumannii, Salmonella spp, Staphylococcus aureus, and Streptococcus pneumoniae). Although E coli and Klebsiella spp resistance to third-generation cephalosporins is common in all countries, with prevalence reaching more than 50% in Egypt and Syria, carbapenem resistance is emerging, albeit with a prevalence of less than 10%. Conversely, a large amount of carbapenem resistance has been reported for P aeruginosa and A baumannii across the Arab League, reaching 50% and 88% of isolates in some countries. As for Salmonella spp, the prevalence of fluoroquinolone resistance has exceeded 30% in several areas. With regards to the Gram-positive pathogens, the prevalence of meticillin resistance in S aureus is reported to be between 20% and 30% in most countries, but exceeds 60% in Egypt and Iraq. The prevalence of penicillin non-susceptibility among pneumococci has reached more than 20% in Algeria, Egypt, Morocco, Saudi Arabia, and Tunisia. These findings highlight the need for structured national plans in the region to target infection prevention and antimicrobial stewardship.
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Affiliation(s)
- Rima A Moghnieh
- Division of Infectious Diseases, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
| | - Zeina A Kanafani
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussam Z Tabaja
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Sima L Sharara
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lyn S Awad
- Pharmacy Department, Makassed General Hospital, Beirut, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
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Kim YK, Song SA, Lee JN, Oh M, Jo KM, Kim HJ, Lee JH, Park J, Jang HJ, Kim HK, Kiem S. Clinical factors predicting persistent carriage of Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacteriaceae among patients with known carriage. J Hosp Infect 2018; 99:405-412. [PMID: 29111353 DOI: 10.1016/j.jhin.2017.10.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Information on the natural duration of carbapenem-resistant Enterobacteriaceae (CRE) carriage and factors associated with persistence of carriage is limited. AIM To evaluate the clinical variables associated with persistent carriage of Klebsiella pneumoniae carbapenemase (KPC)-producing CRE. METHODS Data for patients admitted between June 2015 and December 2016 who were identified as KPC-producing CRE carriers by either rectal swabs or clinical cultures were reviewed retrospectively. Patients with follow-up culture data for three months after initial acquisition were included. Regression models were used to evaluate the clinical variables associated with persistence of carriage. FINDINGS Of the 100 eligible patients, 50 patients (50%) experienced spontaneous decolonization within three months. Among the 50 patients (50%) who remained culture positive after three months, 26 patients carried KPC-producing CRE after six months. Multi-variable analysis revealed that re-admission [adjusted odds ratio (aOR) 9.96; 95% confidence interval (CI) 1.13-87.98; P=0.039], duration of hospitalization (aOR 1.03; 95% CI 1.01-1.05; P=0.003), positive clinical culture (aOR 6.26; 95% CI 1.28-30.54; P=0.023) and carbapenem use (OR 9.15; 95% CI 1.85-45.27; P=0.007) were predictive for persistent carriage after six months. CONCLUSION The results suggest that patients with KPC-producing CRE in clinical specimens who are using carbapenem, particularly those with multiple and prolonged hospitalizations, are more likely to remain carriers after six months of initial acquisition. This information is useful for coordinating strategies for pre-emptive isolation by predicting the CRE carriage status appropriately, and ensuring active surveillance through risk factor stratification.
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Affiliation(s)
- Y K Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - S A Song
- Department of Laboratory Medicine, Inje University College of Medicine, Busan, Republic of Korea
| | - J N Lee
- Department of Laboratory Medicine, Inje University College of Medicine, Busan, Republic of Korea
| | - M Oh
- Department of Pharmacology, Clinical Trial Centre, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - K M Jo
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-J Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - J H Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - J Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-J Jang
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - H-K Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - S Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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Molina J, Peñalva G, Gil-Navarro MV, Praena J, Lepe JA, Pérez-Moreno MA, Ferrándiz C, Aldabó T, Aguilar M, Olbrich P, Jiménez-Mejías ME, Gascón ML, Amaya-Villar R, Neth O, Rodríguez-Hernández MJ, Gutiérrez-Pizarraya A, Garnacho-Montero J, Montero C, Cano J, Palomino J, Valencia R, Álvarez R, Cordero E, Herrero M, Cisneros JM. Long-Term Impact of an Educational Antimicrobial Stewardship Program on Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections: A Quasi-Experimental Study of Interrupted Time-Series Analysis. Clin Infect Dis 2018; 65:1992-1999. [PMID: 29020166 DOI: 10.1093/cid/cix692] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/03/2017] [Indexed: 01/08/2023] Open
Abstract
Background The global crisis of bacterial resistance urges the scientific community to implement intervention programs in healthcare facilities to promote an appropriate use of antibiotics. However, the clinical benefits or the impact on resistance of these interventions has not been definitively proved. Methods We designed a quasi-experimental intervention study with an interrupted time-series analysis. A multidisciplinary team conducted a multifaceted educational intervention in our tertiary-care hospital over a 5-year period. The main activity of the program consisted of peer-to-peer educational interviews between counselors and prescribers from all departments to reinforce the principles of the proper use of antibiotics. We assessed antibiotic consumption, incidence density of Candida and multidrug-resistant (MDR) bacteria bloodstream infections (BSIs) and their crude death rate per 1000 occupied bed days (OBDs). Results A quick and intense reduction in antibiotic consumption occurred 6 months after the implementation of the intervention (change in level, -216.8 defined daily doses per 1000 OBDs; 95% confidence interval, -347.5 to -86.1), and was sustained during subsequent years (average reduction, -19,9%). In addition, the increasing trend observed in the preintervention period for the incidence density of candidemia and MDR BSI (+0.018 cases per 1000 OBDs per quarter; 95% confidence interval, -.003 to .039) reverted toward a decreasing trend of -0.130 per quarter (change in slope, -0.029; -.051 to -.008), and so did the mortality rate (change in slope, -0.015; -.021 to -.008). Conclusions This education-based antimicrobial stewardship program was effective in decreasing the incidence and mortality rate of hospital-acquired candidemia and MDR BSI through sustained reduction in antibiotic use.
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Affiliation(s)
- José Molina
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Germán Peñalva
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | | | | | - José A Lepe
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | | | | | | | - Manuela Aguilar
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Peter Olbrich
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville
| | | | | | | | - Olaf Neth
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville
| | | | | | - José Garnacho-Montero
- Department of Critical Care, University Hospital Virgen Macarena, University of Seville
| | - Cristina Montero
- Department of Pediatric Critical Care and Emergency, University Hospital Virgen del Rocio, Seville, Spain
| | - Josefina Cano
- Department of Pediatric Critical Care and Emergency, University Hospital Virgen del Rocio, Seville, Spain
| | - Julián Palomino
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Raquel Valencia
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Rocío Álvarez
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Elisa Cordero
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Marta Herrero
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - José M Cisneros
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Karampatakis T, Tsergouli K, Iosifidis E, Antachopoulos C, Karapanagiotou A, Karyoti A, Gritsi-Gerogianni N, Tsakris A, Roilides E. Impact of active surveillance and infection control measures on carbapenem-resistant Gram-negative bacterial colonization and infections in intensive care. J Hosp Infect 2018; 99:396-404. [PMID: 29792971 DOI: 10.1016/j.jhin.2018.05.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/15/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Carbapenem-resistant Gram-negative bacteria (CRGNB) infections constitute a global threat for critically ill patients and the outcome of their hospitalization. Early identification of CRGNB through rectal surveillance cultures and routine infection control measures including contact precautions, use of appropriate disinfectants, staff education on cleaning, and hand hygiene may reduce the dissemination of CRGNB. AIM To assess the impact of enhanced infection control measures on CRGNB infections in a nine-bed polyvalent intensive care unit in a tertiary level hospital in an endemic area. METHODS A quasi-experimental study, which included patients with CRGNB infection retrospectively for six months and those participating in an active surveillance programme prospectively for the subsequent 22 months. Active surveillance programme (weekly rectal swabs) was implemented including two sub-periods with infection control measures and enhanced infection control measures. CRGNB incidence, prevalence, colonization pressure, infections and compliance with infection control measures and enhanced infection control measures were recorded. Analysis was performed through time-series and interrupted time-series. FINDINGS During the active surveillance programme, enhanced infection control measures led to a steeper downwards trend in incidence, prevalence, and colonization pressure for CRGNB compared to the infection control measures sub-period. The linear trend was for carbapenem-resistant Klebsiella pneumoniae (CRKP) and Pseudomonas aeruginosa (CRPA) infections to decrease from 19.6 to 8.1 infections per 1000 bed-days (IBD) (P = 0.001) and from 5.1 to 1.79 IBD (P = 0.043), respectively. By contrast, carbapenem-resistant Acinetobacter baumannii infections increased from 5.2 to 15.3 IBD (P = 0.001). CONCLUSION Enhanced infection control measures including enhanced hand hygiene, active surveillance combined with contact precautions, education, audits and feedback policies and interventions could reduce CRKP and CRPA in endemic areas.
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Affiliation(s)
- T Karampatakis
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - K Tsergouli
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - E Iosifidis
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - C Antachopoulos
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - A Karapanagiotou
- Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - A Karyoti
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | | | - A Tsakris
- Microbiology Department, National and Kapodistrian University School of Medicine, Athens, Greece
| | - E Roilides
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece.
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Abstract
Background Carbapenem resistance in Gram-negative bacteria is increasing in many countries and use of carbapenems and antibiotics to which resistance is linked should be reduced to slow its emergence. There are no directly equivalent antibiotics and the alternatives are less well supported by clinical trials. The few new agents are expensive. Objectives To provide guidance on strategies to reduce carbapenem usage. Methods A literature review was performed as described in the BSAC/HIS/BIA/IPS Joint Working Party on Multiresistant Gram-negative Infection Report. Results Older agents remain active against some of the pathogens, although expectations of broad-spectrum cover for empirical treatment have risen. Education, expert advice on treatment and antimicrobial stewardship can produce significant reductions in use. Conclusions More agents may need to be introduced onto the antibiotic formulary of the hospital, despite the poor quality of scientific studies in some cases.
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Affiliation(s)
- A Peter R Wilson
- Department of Microbiology & Virology, University College London Hospitals, London, UK
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Rationale Antibiotikaverordnung in der Humanmedizin. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:580-588. [DOI: 10.1007/s00103-018-2727-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Gaibani P, Campoli C, Lewis RE, Volpe SL, Scaltriti E, Giannella M, Pongolini S, Berlingeri A, Cristini F, Bartoletti M, Tedeschi S, Ambretti S. In vivo evolution of resistant subpopulations of KPC-producing Klebsiella pneumoniae during ceftazidime/avibactam treatment. J Antimicrob Chemother 2018; 73:1525-1529. [DOI: 10.1093/jac/dky082] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/15/2018] [Indexed: 02/03/2023] Open
Affiliation(s)
- Paolo Gaibani
- Operative Unit of Clinical Microbiology, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Caterina Campoli
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Russell E Lewis
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Department of Medical and Surgical Sciences DIMEC, University of Bologna, Bologna, Italy
| | - Silvia Lidia Volpe
- Operative Unit of Clinical Microbiology, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Erika Scaltriti
- Risk Analysis Unit, Istituto Zooprofilattico Sperimentale della Lombardia e dell’Emilia Romagna (IZSLER), Parma, Italy
| | - Maddalena Giannella
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Department of Medical and Surgical Sciences DIMEC, University of Bologna, Bologna, Italy
| | - Stefano Pongolini
- Risk Analysis Unit, Istituto Zooprofilattico Sperimentale della Lombardia e dell’Emilia Romagna (IZSLER), Parma, Italy
| | - Andrea Berlingeri
- Operative Unit of Clinical Microbiology, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Cristini
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Bartoletti
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Sara Tedeschi
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Simone Ambretti
- Operative Unit of Clinical Microbiology, S. Orsola-Malpighi University Hospital, Bologna, Italy
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Kalaba M, Kosutic J, Godman B, Radonjic V, Vujic A, Jankovic S, Srebro D, Kalaba Z, Stojanovic R, Prostran M. Experience with developing antibiotic stewardship programs in Serbia: potential model for other Balkan countries? J Comp Eff Res 2018; 7:247-258. [DOI: 10.2217/cer-2017-0055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Antimicrobial resistance and inappropriate use of antibiotics in children are important issues. Consequently, there is a need to develop comprehensive stewardship programs even in hospitals with limited resources starting with children's hospitals. Methods: Retrospective observational analysis of antimicrobial utilization and resistance patterns over 5 years in a tertiary care children's hospital in Serbia. Results: Cumulative antimicrobial resistance decreased but was still high, with high cumulative resistance rates among the most widely used antibiotics in the hospital. Total antibiotic use decreased from 2010 to 2014 although there was still high prescribing of reserved antibiotics. Conclusion: Concerns with inappropriate use and high resistance rates among some antibiotics used in the hospital are being used to develop guidance on future antibiotic use in this hospital, building on the recently introduced antibiotic stewardship program, as well as encourage other hospitals in Serbia to review their policies.
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Affiliation(s)
- Marija Kalaba
- Primary Healthcare Centre ‘Zemun’, Šilerova 46, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jovan Kosutic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- The Institute for Medical Care of Mother & Child of Serbia ‘Dr Vukan Cupic’, Radoja Dakića, Belgrade, Serbia
| | - Brian Godman
- Strathclyde Institute of Pharmacy & Biomedical Sciences, Strathclyde University, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden
- Health Economics Centre, Liverpool University Management School, Liverpool, UK
| | - Vesela Radonjic
- Medicine & Medical Device Agency of Serbia, Belgrade, Serbia
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Serbia
| | - Ana Vujic
- Clinical Center Kragujevac, Zmaj Jovina street 30, Kragujevac, Serbia
| | - Slobodan Jankovic
- Clinical Center Kragujevac, Zmaj Jovina street 30, Kragujevac, Serbia
| | - Dragana Srebro
- The Institute for Medical Care of Mother & Child of Serbia ‘Dr Vukan Cupic’, Radoja Dakića, Belgrade, Serbia
| | - Zlatko Kalaba
- Children Hospital for Pulmonary Diseases & Tuberculosis at University Hospital Center ‘Dr Dragisa Misovic’, Belgrade, Serbia
| | - Radan Stojanovic
- The Institute for Medical Care of Mother & Child of Serbia ‘Dr Vukan Cupic’, Radoja Dakića, Belgrade, Serbia
- Clinical Pharmacology Unit, Clinical Center Serbia, Belgrade, Serbia
| | - Milica Prostran
- The Institute for Medical Care of Mother & Child of Serbia ‘Dr Vukan Cupic’, Radoja Dakića, Belgrade, Serbia
- Clinical Pharmacology Unit, Clinical Center Serbia, Belgrade, Serbia
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Bartoletti M, Tedeschi S, Pascale R, Raumer L, Maraolo AE, Palmiero G, Tumietto F, Cristini F, Ambretti S, Giannella M, Lewis RE, Viale P. Differences in the rate of carbapenem-resistant Enterobacteriaceae colonisation or Clostridium difficile infection following frontline treatment with tigecycline vs. meropenem for intra-abdominal infections. Int J Antimicrob Agents 2018; 51:516-521. [PMID: 29410250 DOI: 10.1016/j.ijantimicag.2018.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/29/2017] [Accepted: 01/13/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We hypothesised that treatment with a tigecycline-based antimicrobial regimen for intra-abdominal infection (IAI) could be associated with lower rates of subsequent carbapenem-resistant Enterobacteriaceae (CRE) colonisation or Clostridium difficile infection (CDI) compared with a meropenem-based regimen. METHODS We performed a retrospective, single-centre, matched (1:1) cohort analysis of all patients who received at least 5 days of empirical or targeted tigecycline (TIG)- or meropenem (MER)-based treatment regimens for IAI over a 50-month period. Patients with previous CRE colonisation and CDI were excluded. Risk factors for CRE and CDI were assessed with a Cox regression model that included treatment duration as a time-dependent variable. Thirty-day mortality was assessed with Kaplan-Meier curves. RESULTS We identified 168 TIG-treated and 168 MER-treated patients. The cumulative incidence rate ratio of CDI was 10-fold lower in TIG-treated vs. MER-treated patients (incidence rate ratio [IRR] 0.10/1000 patient-days, 95%CI 0.002-0.72, P = 0.007), but similar incidence rates were found for CRE colonisation (IRR 1.39/1000 patient-days, 95%CI 0.68-2.78, P = 0.36). In a multivariate Cox regression model, the receipt of a TIG- vs. MER-based regimen was associated with significantly lower rates of CDI (HR 0.07, 95%CI 0.03-0.71, P = 0.02), but not CRE (HR 1.12, 95% CI 0.45-2.83, P = 0.80). All-cause 30-day mortality was similar in the two groups (P = 0.46). CONCLUSION TIG-based regimens for IAI were associated with a 10-fold lower incidence of CDI compared with MER-based regimens, but there was no difference in the incidence of CRE colonisation.
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Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Luigi Raumer
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, via Sergio Pansini 5, 80131, Naples, Italy
| | - Giulia Palmiero
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, via Sergio Pansini 5, 80131, Naples, Italy
| | - Fabio Tumietto
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Francesco Cristini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Simone Ambretti
- Operative Unit of Clinical Microbiology, S. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Russell Edward Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
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Liu J, Yu J, Chen F, Yu J, Simner P, Tamma P, Liu Y, Shen L. Emergence and establishment of KPC-2-producing ST11 Klebsiella pneumoniae in a general hospital in Shanghai, China. Eur J Clin Microbiol Infect Dis 2018; 37:293-299. [PMID: 29282569 PMCID: PMC5780533 DOI: 10.1007/s10096-017-3131-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/02/2017] [Indexed: 11/24/2022]
Abstract
The aim of this study was to investigate the characteristics of carbapenem-resistant Klebsiella pneumoniae (CRKP) collected during an outbreak in a Chinese teaching hospital and to provide insights into the prevention and control of nosocomial infection. We collected unique CRKP clinical isolates from 2009 to 2013. Antibiotic-resistant genes were identified by polymerase chain reaction (PCR) and sequencing. The isolates were typed using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Plasmids were classified using a PCR-based incompatibility/replicon typing method and a replicon sequence typing method. Conjugation experiments were performed to evaluate the transferability of carbapenem-resistant genes. Whole genome sequencing (WGS) was conducted to further investigate the genetic background of the isolates. Infection control practices were reviewed throughout the study period. Klebsiella pneumoniae sequence type (ST) 11 emerged in 2010 and acquired the bla KPC-2 gene by 2011. From 2011 to 2013, ST11 KPC-2-producing CRKP (G type) prevailed as the most common CRKP in our hospital, causing a prolonged outbreak. The majority of these CRKP strains possess an IncFII plasmid, with Tn1721-bla KPC-2-ΔTn3-IS26 bearing the genetic structure for bla KPC-2. Infection prevention control measures available at the time contained the initial outbreak, but had no effect on the spread of CRKP later. This study demonstrated the seriousness concerning the spread of KPC-2-producing ST11 CRKP in a Chinese hospital, indicating that current prevention and control strategies for carbapenem-resistant Enterobacteriaceae (CRE) nosocomial infection need to be investigated and adjusted.
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Affiliation(s)
- Jingxian Liu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Yu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Chen
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiajia Yu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Patricia Simner
- Department of Pathology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pranita Tamma
- Department of Pathology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ying Liu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Lisong Shen
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Abstract
PURPOSE OF REVIEW Multidrug-resistant (MDR) Enterobacteriaceae are often related to the production of extended-spectrum b-lactamases (ESBLs) and carbapenemase-producing Enterobacteriaceae (CRE), and represent an increasing global threat. Recommendations for the therapeutic management of MDR-related infections, however, are mainly derived from retrospective and nonrandomized prospective studies. The aim of this review is to discuss the challenges in the treatment of patients with infections because of MDR Enterobacteriaceae and provide an expert opinion while awaiting for more definitive data. RECENT FINDINGS To avoid the selection of carbapenemase-producing Enterobacteriaceae, carbapenem-sparing strategies should be considered. B-lactams/b-lactamase inhibitors, mainly piperacillin-tazobactam, minimum inhibitory concentration (MIC) 16/4mg/ml or less represents the best alternative to carbapenems for the treatment of ESBL-producing strains. Overall, combination therapy may be preferred over monotherapy for CRE. The combination of a carbapenem-containing regimen with colistin or high-dose tigecycline or aminoglycoside can be administered at high-dose prolonged infusion with therapeutic drug monitoring for the treatment of CRE with MIC for meropenem 8-16 mg/l or less. For MIC higher than 8-16 mg/l, the use of meropenem should be avoided and various combination therapies based on the in-vitro susceptibility of antimicrobials (e.g., colistin, high-dose tigecycline, fosfomycin, and aminoglycosides) should be selected. SUMMARY Carbapenem-sparing strategies should be used, when feasible, for ESBL infections. The majority of available nonrandomized studies highlight that combination for CRE seem to offer some therapeutic advantage over monotherapy. Strict infection control measures toward MDR Gram-negative pathogens remain necessary while awaiting for new treatment options.
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van Loon K, Voor In 't Holt AF, Vos MC. A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2018; 62:e01730-17. [PMID: 29038269 PMCID: PMC5740327 DOI: 10.1128/aac.01730-17] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/29/2017] [Indexed: 01/23/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.
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Affiliation(s)
- Karlijn van Loon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Bassetti M, Giacobbe DR, Giamarellou H, Viscoli C, Daikos GL, Dimopoulos G, De Rosa FG, Giamarellos-Bourboulis EJ, Rossolini GM, Righi E, Karaiskos I, Tumbarello M, Nicolau DP, Viale PL, Poulakou G. Management of KPC-producing Klebsiella pneumoniae infections. Clin Microbiol Infect 2017; 24:133-144. [PMID: 28893689 DOI: 10.1016/j.cmi.2017.08.030] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/17/2017] [Accepted: 08/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas. AIMS To provide practical suggestion for physicians dealing with the management of KPC-KP infections in critically ill patients, based on expert opinions. SOURCES PubMed search for relevant publications related to the management of KPC-KP infections. CONTENTS A panel of experts developed a list of 12 questions to be addressed. In view of the current lack of high-level evidence, they were asked to provide answers on the bases of their knowledge and experience in the field. The panel identified several key aspects to be addressed when dealing with KPC-KP in critically ill patients (preventing colonization in the patient, preventing infection in the colonized patient and colonization of his or her contacts, reducing mortality in the infected patient by rapidly diagnosing the causative agent and promptly adopting the best therapeutic strategy) and provided related suggestions that were based on the available observational literature and the experience of panel members. IMPLICATIONS Diagnostic technologies could speed up the diagnosis of KPC-KP infections. Combination treatment should be preferred to monotherapy in cases of severe infections. For non-critically ill patients without severe infections, results from randomized clinical trials are needed for ultimately weighing benefits and costs of using combinations rather than monotherapy. Multifaceted infection control interventions are needed to decrease the rates of colonization and cross-transmission of KPC-KP.
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Affiliation(s)
- M Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy.
| | - D R Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - H Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - C Viscoli
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - G L Daikos
- 1st Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - F G De Rosa
- Department of Medical Science, University of Turin, Infectious Diseases Amedeo di Savoia Hospital, Turin, Italy
| | - E J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G M Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - E Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | - I Karaiskos
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - M Tumbarello
- Institute of Infectious Diseases Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - D P Nicolau
- Center for Anti-infective Research and Development, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - P L Viale
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - G Poulakou
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
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