1
|
Müller M, Wiencierz A, Gehringer C, Muigg V, Bassetti S, Siegemund M, Hinic V, Tschudin-Sutter S, Egli A. Factors associated with non-carbapenemase mediated carbapenem resistance of Gram-negative bacteria: a retrospective case-control study. Int Microbiol 2024; 27:597-606. [PMID: 37556067 PMCID: PMC10991015 DOI: 10.1007/s10123-023-00405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 08/10/2023]
Abstract
Infections with carbapenemase-producing Gram-negative bacteria are related to increased morbidity and mortality, yet little is known regarding infections caused by non-beta-lactamase mediated carbapenem-resistant bacteria. Our objective was to identify risk factors for, and the clinical impact of infections caused by carbapenem-resistant carbapenemase-negative Enterobacterales and Pseudomonas aeruginosa. This retrospective matched case-control study was performed at the University Hospital of Basel, Switzerland, in 2016. We focused on other resistance mechanisms by excluding laboratory-confirmed carbapenemase-positive cases. Carbapenem resistance was set as the primary endpoint, and important risk factors were investigated by conditional logistic regression. The clinical impact of carbapenem resistance was estimated using regression models containing the resistance indicator as explanatory factor and adjusting for potential confounders. Seventy-five cases of infections with carbapenem-resistant, carbapenemase-negative bacteria were identified and matched with 75 controls with carbapenem-susceptible infections. The matched data set was well-balanced regarding age, gender, and comorbidity. Duration of prior carbapenem treatment (OR 1.15, [1.01, 1.31]) correlated with resistance to carbapenems. Our study showed that patients with carbapenem-resistant bacteria stayed 1.59 times (CI [0.81, 3.14]) longer in an ICU. The analyzed dataset did not provide evidence for strong clinical implications of resistance to carbapenems or increased mortality. The duration of prior carbapenem treatment seems to be a strong risk factor for the development of carbapenem resistance. The higher risk for a longer ICU stay could be a consequence of a carbapenem resistance. In contrast to carbapenemase-producers, the clinical impact of carbapenamase-negative, carbapenem-resistant strains may be limited. Trial registration: The study design was prospectively approved by the local Ethics Commission on 10.08.2017 (EKNZ BASEC 2017-00222).
Collapse
Affiliation(s)
- Marius Müller
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Christian Gehringer
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Veronika Muigg
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Medicine, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Vladimira Hinic
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland.
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland.
- Institute of Medical Microbiology, University of Zurich, Gloriastrasse 28/30, 8006, Zurich, Switzerland.
| |
Collapse
|
2
|
Ndlovu T, Kgosietsile L, Motshwarakgole P, Ndlovu SI. Evaluation of Potential Factors Influencing the Dissemination of Multidrug-Resistant Klebsiella pneumoniae and Alternative Treatment Strategies. Trop Med Infect Dis 2023; 8:381. [PMID: 37624319 PMCID: PMC10459473 DOI: 10.3390/tropicalmed8080381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing reports of multidrug-resistant Klebsiella pneumoniae have emerged as a public health concern, raising questions about the potential routes for the evolution and dissemination of the pathogenic K. pneumoniae into environmental reservoirs. Potential drivers of the increased incidence of antimicrobial-resistant environmental K. pneumoniae include the eminent global climatic variations as a direct or indirect effect of human activities. The ability of microorganisms to adapt and grow at an exponential rate facilitates the distribution of environmental strains with acquired resistant mutations into water systems, vegetation, and soil which are major intersection points with animals and humans. The bacterial pathogen, K. pneumoniae, is one of the critical-priority pathogens listed by the World Health Organization, mostly associated with hospital-acquired infections. However, the increasing prevalence of pathogenic environmental strains with similar characteristics to clinical-antibiotic-resistant K. pneumoniae isolates is concerning. Considering the eminent impact of global climatic variations in the spread and dissemination of multidrug-resistant bacteria, in this review, we closely assess factors influencing the dissemination of this pathogen resulting in increased interaction with the environment, human beings, and animals. We also look at the recent developments in rapid detection techniques as part of the response measures to improve surveillance and preparedness for potential outbreaks. Furthermore, we discuss alternative treatment strategies that include secondary metabolites such as biosurfactants and plant extracts with high antimicrobial properties.
Collapse
Affiliation(s)
- Thando Ndlovu
- Department of Biological Sciences, Faculty of Science, University of Botswana, Private Bag UB, Gaborone 0022, Botswana; (L.K.); (P.M.)
| | - Lebang Kgosietsile
- Department of Biological Sciences, Faculty of Science, University of Botswana, Private Bag UB, Gaborone 0022, Botswana; (L.K.); (P.M.)
| | - Pako Motshwarakgole
- Department of Biological Sciences, Faculty of Science, University of Botswana, Private Bag UB, Gaborone 0022, Botswana; (L.K.); (P.M.)
| | - Sizwe I. Ndlovu
- Department of Biotechnology and Food Technology, Doornfontein Campus, University of Johannesburg, Johannesburg 2028, South Africa;
| |
Collapse
|
3
|
DERİN O, ŞEKER F, AKSOY N, YIGIT P, YILMAZ M, MERT A. The Effect of Antimicrobial Policy Implementation on Carbapenem Resistance: A University Hospital Experience. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2022. [DOI: 10.33808/clinexphealthsci.1010571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The resistance of Gram-negative bacteria to antibiotics is a global issue that leads to increased mortality and treatment costs. The aim of this study is to see how a newly formed carbapenem control team affected the prevalence of carbapenem-resistant Gram-negative rods and antibiotic consumption expenses in 2017 compared to the year before.
Methods: The rate of carbapenem antibiotic usage in Intensive Care Units and Bone Marrow Transplantation services, as well as the findings of culture materials obtained from various body parts of the same patients, between January 1, 2016, and December 31, 2017 were assessed.
Results: While there was an ordinary restriction on carbapenem consumption in 2016, carbapenem consumption has been more restricted in 2017. The carbapenem-resistant Gram-negative bacteria patterns of culture materials are examined and compared with Defined Daily Dose data of carbapenems. After the restriction, a significant decrease in the consumption of carbapenems was detected. The decline in carbapenem-resistant Gram-negative bacteria and decreasing antibiotic consumption were found to have a moderately positive correlation (r=0.641, p=0.02). A 60.9% decrease was observed in carbapenem costs after carbapenem restriction, on the other hand, an increase in other unrestricted antibiotics was apparent.
Conclusion: Antimicrobial restriction policies can help minimize the rate of carbapenem-resistant Gram-negative rods, which is a serious problem in healthcare. We demonstrated that a decrease in carbapenem-resistant Gram-negative rods isolation rates can lead to a decrease in healthcare-associated infections. Although there is no decrease in the direct antibiotics cost, a drop in carbapenem-resistant may lower the expenses of drastic consequences of infections with carbapenem-resistant and its cost. we can conclude that the Antibiotic Control Policy should be modified based on this new information.
Collapse
|
4
|
Hernández-García M, Díaz-Agero C, Pérez-Viso B, Sánchez AM, López-Fresneña N, Morosini MI, Ruiz-Garbajosa P, Cantón R. Implementation of contact isolation strategy for the containment of extended-spectrum β-lactamase carriers in a University Hospital positively affects the epidemiology of carbapenemase-producing Enterobacterales. ACTA ACUST UNITED AC 2021; 39:429-435. [PMID: 34736747 DOI: 10.1016/j.eimce.2020.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/03/2020] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The lack of consensus of control measures to prevent extended-spectrum β-lactamase producing Enterobacterales (ESBL-E) transmission in the hospital setting is of great concern. We describe the prevalence and species distribution of ESBL-E and carbapenemase producing Enterobacterales (CPE) in patients admitted in a tertiary Hospital during an active surveillance screening program for detecting ESBL-E carriers and reducing the ESBL-E transmission (R-GNOSIS Project). METHODS From March-2014 to March-2016, 15,556 rectal swabs were collected from 8209 patients admitted in two medical (Gastroenterology, Pneumology) and two surgical (Neurosurgery, Urology) wards. Swabs were seeded onto ChromoID-ESBL and -CARB/OXA-48 agar plates. Growing colonies were identified by MALDI-TOF MS. ESBL and carbapenemases were phenotypically detected. Changes in species diversity (SDI) and distribution over time were analyzed. RESULTS ESBL-E incidence (8.4%) tended to decrease over time (p=0.003) and CPE carrier prevalence remained unchanged during the study (2%). The contact isolation strategy targeted to reduce ESBL-E transmission was ineffective in reducing ESBL-E carriers but significant differences were observed with CPE (p=0.017). SDI did not change among ESBL-E and E. coli was predominant (78.5%) during the study. K. pneumoniae (54%) was the most frequent CPE species, followed by E. coli (19%). SDI decreased among the CPE population over time mainly due to K. pneumoniae dominance and increased E. coli prevalence in the last part of the study. CONCLUSIONS During the R-GNOSIS project, contact precautions were not effective in reducing the ESBL-E transmission but may have had a positive collateral effect on the CPE containment.
Collapse
Affiliation(s)
- Marta Hernández-García
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Cristina Díaz-Agero
- Servicio de Medicina Preventiva, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Blanca Pérez-Viso
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Ana María Sánchez
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Nieves López-Fresneña
- Servicio de Medicina Preventiva, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Isabel Morosini
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Patricia Ruiz-Garbajosa
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain.
| |
Collapse
|
5
|
Han R, Teng M, Zhang Y, Zhang T, Wang T, Chen J, Li S, Yang B, Shi Y, Dong Y, Wang Y. Choosing Optimal Antibiotics for the Treatment of Patients Infected With Enterobacteriaceae: A Network Meta-analysis and Cost-Effectiveness Analysis. Front Pharmacol 2021; 12:656790. [PMID: 34220501 PMCID: PMC8245689 DOI: 10.3389/fphar.2021.656790] [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: 01/22/2021] [Accepted: 06/04/2021] [Indexed: 11/13/2022] Open
Abstract
Overuse of carbapenems has led to the increasing carbapenem-resistant Enterobacteriaceae. It is still unknown whether other antibiotics [especially novel β-lactam/β-lactamase inhibitor combinations (BL/BLIs)] are better than carbapenems in the treatment of Enterobacteriaceae. A systematic literature search was performed to identify randomized controlled trials (RCTs) assessing the efficacy and safety of any antibiotics on Enterobacteriaceae infections. We carried out a traditional paired meta-analysis to compare ceftazidime/avibactam to comparators. Network meta-analysis (NMA) was conducted to integrate direct and indirect evidence of all interventions. Moreover, cost-effectiveness analysis using a combined decision analytical Markov model was completed for the treatment of patients with complex urinary tract infection (cUTI). A total of 25 relevant RCTs were identified, comprising 15 different interventions. Ceftazidime/avibactam exhibited comparable efficacy and safety with comparators (carbapenems) in the paired meta-analysis. In the NMA, the surface under the cumulative ranking curve probabilities showed that in terms of efficacy, the interventions with the highest-ranking were meropenem/vaborbactam, meropenem, imipenem/cilastatin, ceftriaxone, ceftazidime/avibactam, and ceftolozane/tazobactam [but no significant difference between any two antibiotics (p > 0.05)]. Regarding safety, ceftazidime/avibactam had a higher incidence of adverse events than that of piperacillin/tazobactam (relative risk = 0.74, 95% confidence interval = 0.59–0.94). Based on drug and hospitalization costs in China, the incremental cost-effectiveness ratio per quality-adjusted life-year gained in the patients with cUTI for meropenem, ceftazidime/avibactam, and ceftolozane/tazobactam compared to imipenem/cilastatin were US$579, US$24569, and US$29040, respectively. The role of these BL/BLIs to serve as alternatives to carbapenems requires large-scale and high-quality studies to validate.
Collapse
Affiliation(s)
- Ruiying Han
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ying Zhang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Tao Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Taotao Wang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yaling Shi
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|
6
|
Prior Antibiotic Therapy and the Onset of Healthcare-Associated Infections Sustained by Multidrug-Resistant Klebsiella pneumoniae in Intensive Care Unit Patients: A Nested Case-Control Study. Antibiotics (Basel) 2021; 10:antibiotics10030302. [PMID: 33804087 PMCID: PMC8000440 DOI: 10.3390/antibiotics10030302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/25/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
Epidemiological research has demonstrated direct relationships between antibiotic consumption and the emergence of multidrug-resistant (MDR) bacteria. In this nested case-control study, we assessed whether prior exposure to antibiotic therapy and its duration affect the onset of healthcare-associated infections (HAIs) sustained by MDR Klebsiella pneumoniae (MDR-Kp) in intensive care unit patients. Cases were defined as patients who developed an MDR-Kp HAI. Controls matched on sex and the length of intensive care unit (ICU) stay were randomly selected from the at-risk population. Any antibiotic agent received in systemic administration before the onset of infection was considered as antibiotic exposure. Multivariable conditional logistic regression analyses were performed to estimate the effect of prior exposure to each antibiotic class (Model 1) or its duration (Model 2) on the onset of HAIs sustained by MDR-Kp. Overall, 87 cases and 261 gender-matched controls were compared. In Model 1, aminoglycosides and linezolid independently increased the likelihood of developing an MDR-Kp HAI, whereas exposure to both linezolid and penicillins reduced the effect of linezolid alone. In Model 2, cumulative exposure to aminoglycosides increased the likelihood of the outcome, as well as cumulative exposures to penicillins and colistin, while a previous exposure to both penicillins and colistin reduced the influence of the two antibiotic classes alone. Our study confirms that aminoglycosides, penicillins, linezolid, and colistin may play a role in favoring the infections sustained by MDR-Kp. However, several double exposures in the time window before HAI onset seemed to hinder the selective pressure exerted by individual agents.
Collapse
|
7
|
Wu D, Chen C, Liu T, Wan Q. Risk Factors for Acquisition of Carbapenem-Resistant Klebsiella pneumoniae and Mortality Among Abdominal Solid Organ Transplant Recipients with K. pneumoniae Infections. Med Sci Monit 2020; 26:e922996. [PMID: 32807765 PMCID: PMC7458125 DOI: 10.12659/msm.922996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background For abdominal solid organ transplant (ASOT) recipients, infection with Klebsiella pneumoniae, particularly carbapenem-resistant K. pneumoniae (CRKP), can be life-threatening. The aims of this study were to characterize the risk factors associated with acquisition of CRKP and 90-day crude mortality among patients. Material/Methods In our cohort study, we retrospectively reviewed 68 K. pneumoniae-infected transplant recipients, studied their demographics, clinical manifestations, microbiology, and outcomes, and determined the risk factors associated with the occurrence of CRKP and crude mortality due to K. pneumoniae infections. Results Sixty-eight ASOT recipients (5.4%) experienced 78 episodes of K. pneumoniae infection. Among these, 20 patients (29.4%) died. The independent risk factors associated with mortality were multiple infected organs or sites (odds ratio=22.034, 95% confidence intervals=4.348–111.653, P=0.001) and septic shock (odds ratio=27.090, 95% confidence intervals=1.841–398.512, P=0.016). Risk factors associated with acquisition of CRKP were multiple infected organs or sites (odds ratio=3.056, 95% confidence intervals=1.091–8.556, P=0.033). Conclusions K. pneumoniae infections, especially CRKP, frequently occurred among ASOT recipients, with a high mortality rate. Multiple infected organs or sites and septic shock were predictors of crude mortality caused by K. pneumoniae infections, while CRKP infections were associated with multiple infected organs or sites. Greater efforts are needed towards improved antibiotic administration, early diagnosis and precise treatment, recognition of septic shock, and reduced length of hospitalization.
Collapse
Affiliation(s)
- Di Wu
- Department of Transplantation, Xiangya Third Hospital of Central South University, Changsha, Hunan, China (mainland)
| | - Chunmei Chen
- Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China (mainland)
| | - Taohua Liu
- Xiangya Medical School, Central South University, Changsha, Hunan, China (mainland)
| | - Qiquan Wan
- Department of Transplantation, Xiangya Third Hospital of Central South University, Changsha, Hunan, China (mainland)
| |
Collapse
|
8
|
Hernández-García M, Díaz-Agero C, Pérez-Viso B, Sánchez AM, López-Fresneña N, Morosini MI, Ruiz-Garbajosa P, Cantón R. Implementation of contact isolation strategy for the containment of extended-spectrum β-lactamase carriers in a University Hospital positively affects the epidemiology of carbapenemase-producing Enterobacterales. Enferm Infecc Microbiol Clin 2020; 39:S0213-005X(20)30210-X. [PMID: 32605842 DOI: 10.1016/j.eimc.2020.05.013] [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] [Received: 03/14/2020] [Revised: 04/27/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The lack of consensus of control measures to prevent extended-spectrum β-lactamase producing Enterobacterales (ESBL-E) transmission in the hospital setting is of great concern. We describe the prevalence and species distribution of ESBL-E and carbapenemase producing Enterobacterales (CPE) in patients admitted in a tertiary Hospital during an active surveillance screening program for detecting ESBL-E carriers and reducing the ESBL-E transmission (R-GNOSIS Project). METHODS From March-2014 to March-2016, 15,556 rectal swabs were collected from 8209 patients admitted in two medical (Gastroenterology, Pneumology) and two surgical (Neurosurgery, Urology) wards. Swabs were seeded onto ChromoID-ESBL and -CARB/OXA-48 agar plates. Growing colonies were identified by MALDI-TOF MS. ESBL and carbapenemases were phenotypically detected. Changes in species diversity (SDI) and distribution over time were analyzed. RESULTS ESBL-E incidence (8.4%) tended to decrease over time (p=0.003) and CPE carrier prevalence remained unchanged during the study (2%). The contact isolation strategy targeted to reduce ESBL-E transmission was ineffective in reducing ESBL-E carriers but significant differences were observed with CPE (p=0.017). SDI did not change among ESBL-E and E. coli was predominant (78.5%) during the study. K. pneumoniae (54%) was the most frequent CPE species, followed by E. coli (19%). SDI decreased among the CPE population over time mainly due to K. pneumoniae dominance and increased E. coli prevalence in the last part of the study. CONCLUSIONS During the R-GNOSIS project, contact precautions were not effective in reducing the ESBL-E transmission but may have had a positive collateral effect on the CPE containment.
Collapse
Affiliation(s)
- Marta Hernández-García
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Cristina Díaz-Agero
- Servicio de Medicina Preventiva, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Blanca Pérez-Viso
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Ana María Sánchez
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Nieves López-Fresneña
- Servicio de Medicina Preventiva, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Isabel Morosini
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Patricia Ruiz-Garbajosa
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain.
| |
Collapse
|
9
|
Risk factors and outcomes of patients colonized with carbapenemase-producing and non–carbapenemase-producing carbapenem-resistant Enterobacteriaceae. Infect Control Hosp Epidemiol 2020; 41:1154-1161. [DOI: 10.1017/ice.2020.266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractObjective:To compare risk factors and outcome of patients colonized with carbapenemase-producing (CP) carbapenem-resistant Enterobactereaceae (CRE) and non–CP-CRE.Design:A comparative historical study.Setting:A 1,000-bed tertiary-care university hospital.Patients:Adults with CP-CRE positive rectal swab cultures, non–CP-CRE positive rectal swab cultures, and negative rectal swab cultures (non-CRE).Methods:CP-CRE and non–CP-CRE colonized adult patients versus patients not colonized with CRE hospitalized during 24 months were included. We identified patients retrospectively through the microbiology laboratory, and we reviewed their files for demographics, underlying diseases, Charlson Index, treatment, and outcome.Results:This study included 447 patients for whom a rectal swab for CRE was obtained: 147 positive for CP-CRE, 147 positive for non–CP-CRE, and 147 negative for both. Patients with CP-CRE and non–CP-CRE versus no CRE more frequently resided in nursing homes (P<0.001), received antibiotics 3 months prior to admission (P < .001), and received glucocorticosteroids 3 months prior to admission (P = .047 and P < .001, respectively). Risk factors unique for non–CP-CRE versus CP-CRE colonization included mechanical ventilation and patient movement between hospital departments. Non–CP-CRE was a predictor for mechanical ventilation 2.5 that of CP-CRE colonization. In-hospital mortality was highest among non–CP-CRE–colonized patients. On COX multivariate regression for mortality prediction age, Charlson index and steroid treatment 3 months before admission influenced mortality (P = .027, P = .023, and P = .013, respectively).Conclusions:Overlapping and unique risk factors are associated with CP-CRE and non–CP-CRE colonization. Non–CP-CRE colonized patients had a higher in-hospital mortality rate.
Collapse
|
10
|
Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Abdel Fattah M, Haquin J, Macgowan A, Grier S, Gibbs J, Chazan B, Yanovskay A, Ben Ami R, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodriguez-Bano J, Morales I, Oliver A, Ruiz De Gopegui E, Cano A, Machuca I, Gozalo-Marguello M, Martinez Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Ceftazidime, Carbapenems, or Piperacillin-tazobactam as Single Definitive Therapy for Pseudomonas aeruginosa Bloodstream Infection: A Multisite Retrospective Study. Clin Infect Dis 2020; 70:2270-2280. [PMID: 31323088 DOI: 10.1093/cid/ciz668] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/16/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The optimal antibiotic regimen for Pseudomonas aeruginosa bacteremia is controversial. Although β-lactam monotherapy is common, data to guide the choice between antibiotics are scarce. We aimed to compare ceftazidime, carbapenems, and piperacillin-tazobactam as definitive monotherapy. METHODS A multinational retrospective study (9 countries, 25 centers) including 767 hospitalized patients with P. aeruginosa bacteremia treated with β-lactam monotherapy during 2009-2015. The primary outcome was 30-day all-cause mortality. Univariate and multivariate, including propensity-adjusted, analyses were conducted introducing monotherapy type as an independent variable. RESULTS Thirty-day mortality was 37/213 (17.4%), 42/210 (20%), and 55/344 (16%) in the ceftazidime, carbapenem, and piperacillin-tazobactam groups, respectively. Type of monotherapy was not significantly associated with mortality in either univariate, multivariate, or propensity-adjusted analyses (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.52-2.46, for ceftazidime; OR, 1.3; 95% CI, 0.67-2.51, for piperacillin-tazobactam, with carbapenems as reference in propensity adjusted multivariate analysis; 542 patients). No significant difference between antibiotics was demonstrated for clinical failure, microbiological failure, or adverse events. Isolation of P. aeruginosa with new resistance to antipseudomonal drugs was significantly more frequent with carbapenems (36/206 [17.5%]) versus ceftazidime (25/201 [12.4%]) and piperacillin-tazobactam (28/332 [8.4%] (P = .007). CONCLUSIONS No significant difference in mortality, clinical, and microbiological outcomes or adverse events was demonstrated between ceftazidime, carbapenems, and piperacillin-tazobactam as definitive treatment of P. aeruginosa bacteremia. Higher rates of resistant P. aeruginosa after patients were treated with carbapenems, along with the general preference for carbapenem-sparing regimens, suggests using ceftazidime or piperacillin-tazobactam for treating susceptible infection.
Collapse
Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet, and Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- APEMAC, France
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Manal Abdel Fattah
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Justine Haquin
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Alasdair Macgowan
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Sally Grier
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Julie Gibbs
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Bibiana Chazan
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa
| | - Anna Yanovskay
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Israel
- Infectious Diseases Unit Sourasky Medical Center, Tel-Aviv
| | - Michal Landes
- Infectious Diseases Unit Sourasky Medical Center, Tel-Aviv
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | | | - Michael Buhl
- Division of Infectious Diseases, Tübingen University Hospital, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tübingen University Hospital, Germany
| | - Jesus Rodriguez-Bano
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla
| | - Isabel Morales
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca
| | - Enrique Ruiz De Gopegui
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, University Hospital Marqués de Valdecilla-IDIVAL, Santander
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, University Hospital Marqués de Valdecilla-IDIVAL, Santander
| | | | | | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Faculty of Medicine, University of Ljubljana
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Faculty of Medicine, University of Ljubljana
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | | | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center, Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa
| | | | | | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| |
Collapse
|
11
|
Segagni Lusignani L, Presterl E, Zatorska B, Van den Nest M, Diab-Elschahawi M. Infection control and risk factors for acquisition of carbapenemase-producing enterobacteriaceae. A 5 year (2011-2016) case-control study. Antimicrob Resist Infect Control 2020; 9:18. [PMID: 31988746 PMCID: PMC6969403 DOI: 10.1186/s13756-019-0668-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/20/2019] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenemase-producing enterobacteriaceae (CPE) are a major threat for severely ill patients. However, only limited data on the epidemiology and on evidence-based infection prevention and control measures are available. The aim of this study was to investigate the epidemiology of patients with CPE, characterizing the CPE isolates by their resistance mechanisms and genetic similarity, to explore risk factors for their acquisition, and to evaluate the effectiveness of the current CPE infection control measures. Methods A retrospective case-control study was performed using data from 2011 to 2016 in a 1800-bed academic hospital in Central Europe, where risk-based screening at patients´ admission is performed. Carbapenem resistance mechanisms of all carbapenem resistant enterobacteriaceae from patients admitted during this period were investigated. Clinical data of the CPE-positive patients were analysed and compared to a matched control group (case-control ratio of 1:3). We performed univariate and multivariate statistical analysis to identify risk factors for CPE acquisition. Results Of 621,623 admitted patients in the study period, 75 patients with carriage of carbapenem resistant enterobacteriaceae were included (0.12/1000 admittances). Carbapenemase-encoding genes were detected in 77.3% (58/75) of patients with carbapenem-resistant enterobacteriaceae. The enzyme blaOXA-48 was found in 34.5% (20/58), blaKPC in 29.3% (17/58), blaNDM enzymes in 20.7% (12/58) and blaVIM in 8.6% (5/58) of the isolates. The overall mortality among CPE patients was 25.9% (15/58) and attributable mortality of CPE was 53.3% (8/15). Multivariate analysis revealed four risk factors to be independent predictors of CPE carriage: the length of hospital admission > 20 days (AOR: 4.9, 95% CI: 1.4–15.5; P < 0.001), hospital admission within the previous year (AOR: 22.3, 95% CI: 3.9–88.4; P < 0.001), exposure to a healthcare facility in a country with high or unknown carbapenem-resistant enterobacteriaceae prevalence 3 months before admission (AOR: 11.8, 95% CI: 2.2–63.2; P < 0.01) and the use of antibiotics longer than 10 days (AOR: 5.2, 95% CI: 1.4–35.9; P < 0.05). The current risk-based screening strategy at hospital admission could not identify 37 (63.8%) of the 58 CPE-positive patients. Epidemiological investigation and genotyping revealed that no outbreaks due to CPE occurred during this period. Conclusion Overall, the CPE carriage rate in patients was very low, the attributable mortality, however, is alarming (53%). BlaOXA-48 and blaKPC were the main cause of carbapenem resistance in enterobacteriaceae. Although the strict application of standard infection control measures was effective for prevention of outbreaks in this setting, an enlarged risk based targeted screening strategy has to be implemented.
Collapse
Affiliation(s)
- Luigi Segagni Lusignani
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Beata Zatorska
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Miriam Van den Nest
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Magda Diab-Elschahawi
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|
12
|
Sternbach N, Leibovici Weissman Y, Avni T, Yahav D. Efficacy and safety of ceftazidime/avibactam: a systematic review and meta-analysis. J Antimicrob Chemother 2019; 73:2021-2029. [PMID: 29659836 DOI: 10.1093/jac/dky124] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/12/2018] [Indexed: 12/29/2022] Open
Abstract
Background Ceftazidime/avibactam is approved for complicated intra-abdominal and urinary tract infections (UTIs) based on results from randomized controlled trials (RCTs). Data regarding its effectiveness in treating hospital-acquired infections or resistant pathogens have not been systematically compiled. Methods A systematic review and meta-analysis including RCTs evaluating ceftazidime/avibactam versus comparator for the treatment of any infection. Primary outcome was 30 day all-cause mortality. Subgroups of hospital-acquired infections and specific resistance phenotypes were planned. Results Seven publications (eight trials, 4093 patients) were included, reporting a baseline ∼25% of ESBL-carrying Enterobacteriaceae. No significant difference between ceftazidime/avibactam and comparator (mostly carbapenem) was demonstrated for 30 day all-cause mortality, late follow-up mortality and clinical response [relative risk (RR) 1.10, 95% CI 0.70-1.72, P = 0.69; RR 1.23, 95% CI 0.87-1.76, P = 0.25; RR 0.98, 95% CI 0.96-1.01, P = 0.21, respectively, without significant heterogeneity]. Higher microbiological response rate was demonstrated with ceftazidime/avibactam in patients with UTI (RR 1.14, 1.0-1.29, P = 0.05, I2 = 51%). No significant difference in clinical response was demonstrated for patients with ceftazidime-resistant pathogens (RR 1.02, 95% CI 0.94-1.10, P = 0.66, I2 = 0%). Results for other subgroups of resistant pathogens or hospital-acquired infection were not available. Serious adverse events (SAEs) were significantly more common with ceftazidime/avibactam (RR 1.24, 95% CI 1.00-1.54, P = 0.05, I2 = 0%). Conclusions Ceftazidime/avibactam is clinically and microbiologically as effective as carbapenems for treatment of infections in a setting of ∼25% ESBL-carrying Enterobacteriaceae. Safety of the drug should be further evaluated owing to a higher rate of SAEs compared with carbapenems. Further studies should assess the drug's effectiveness in the treatment of carbapenemase-producing Enterobacteriaceae.
Collapse
Affiliation(s)
- Neta Sternbach
- Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yaara Leibovici Weissman
- Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Tomer Avni
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| |
Collapse
|
13
|
Taminato M, Fram D, Pereira RRF, Sesso R, Belasco AGS, Pignatari AC, Barbosa DA. Infection related to Klebsiella pneumoniae producing carbapenemase in renal transplant patients. Rev Bras Enferm 2019; 72:760-766. [PMID: 31269143 DOI: 10.1590/0034-7167-2019-0009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/23/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the risk factors related to Klebsiella pneumoniae carbapenemase infection after renal transplantation. METHODS This was a retrospective epidemiological (case-control) study, conducted from October 2011 to march 2016. Transplanted patients with infection by this bacteria during hospitalization were selected as cases. The controls were paired by age, sex, type of donor and transplant time. The proportion of cases and controls was 1:2. RESULTS Thirty hundred and five patients were included in the study (45 cases and 90 controls). The risk factors found for infection by KPC were: time of hospitalization after the transplant (OR: 4.82; CI95% 2.46-9.44), delayed kidney function (OR: 5.60; CI95% 1.91-11.01) and previous infectious for another microorganism ( OR: 34.13 CI95% 3.52-132.00). CONCLUSION The risk of acquisition of this bacterium was directly related to invasive procedures and exposure to the hospital environment. The findings reinforce the importance of prevention measures and control of infection by this microorganism.
Collapse
Affiliation(s)
| | - Dayana Fram
- Universidade Federal de São Paulo. São Paulo, Brasil
| | | | - Ricardo Sesso
- Universidade Federal de São Paulo. São Paulo, Brasil
| | | | | | | |
Collapse
|
14
|
Kontopoulou K, Iosifidis E, Antoniadou E, Tasioudis P, Petinaki E, Malli E, Metallidis S, Vatopoulos A, Malisiovas N. The clinical significance of carbapenem-resistant Klebsiella pneumoniae rectal colonization in critically ill patients: from colonization to bloodstream infection. J Med Microbiol 2019; 68:326-335. [PMID: 30688629 DOI: 10.1099/jmm.0.000921] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To highlight the clinical significance of carbapenem-resistant Klebsiella pneumoniae (CRKP) rectal colonization by examining the risk factors for CRKP rectal colonization and subsequent bloodstream infection (BSI) in critically ill patients. METHODOLOGY Prospective study of CRKP rectal colonization in an intensive care unit (ICU) during a 39-month period. CRKP strains isolated from both the blood cultures and corresponding rectal specimens (n=96) of patients were screened by PCR for the presence of antibiotic resistance-associated genes. Molecular analyses were conducted to investigate the clonal relatedness of CRKP strains from the rectal and blood specimens. RESULTS Among the 498 patients, 226 were rectally colonized by CRKP, 48 of whom developed a CRKP BSI. The median time from hospital admission to the detection of CRKP rectal colonization was 8 days, while the median time from colonization to BSI was 4 days. The duration of ICU stay, patient/nurse ratio and prior use of antianaerobic antimicrobials were associated with CRKP rectal colonization. No specific factor was associated with BSIs in the colonized patients. The blaKPC-2 gene was detected in all 96 strains, which were all classified as sequence type ST-258. Representative pairs (n=48) of CRKP strains colonizing and infecting the same patient shared the same pulsotype. CONCLUSION Our results indicate that hospitalized patients become infected with their colonizing strains, supporting the strong association between colonization and BSI. Limiting antianaerobic antimicrobial administration, reducing the duration of ICU stay and maintaining a low patient/nurse ratio are possible strategies to restrict rectal CRKP colonization in ICUs.
Collapse
Affiliation(s)
| | - Elias Iosifidis
- 2 3rd Department of Pediatrics, Hippokration Hospital, Aristotle University, Thessaloniki, Greece
| | | | | | - Efthymia Petinaki
- 4 Department of Microbiology, Medical School, University of Thessaly, Larissa, Greece
| | - Ergina Malli
- 4 Department of Microbiology, Medical School, University of Thessaly, Larissa, Greece
| | - Symeon Metallidis
- 5 1st Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Greece
| | | | - Nicolaos Malisiovas
- 7 Department of Microbiology, Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece
| |
Collapse
|
15
|
Mohan B, Prasad A, Kaur H, Hallur V, Gautam N, Taneja N. Fecal carriage of carbapenem-resistant Enterobacteriaceae and risk factor analysis in hospitalised patients: A single centre study from India. Indian J Med Microbiol 2018; 35:555-562. [PMID: 29405149 DOI: 10.4103/ijmm.ijmm_17_144] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Carbapenem-resistant Enterobacteriaceae (CRE) have emerged and disseminated widely causing a variety of infections. In India, the carriage of CRE in hospitalised patients has not been well-studied. Therefore, we conducted the present study to observe gut carriage rate of CRE in patients admitted to our tertiary care hospital. METHODS A total of 232 faecal swabs collected from consecutive stool samples from admitted patients were inoculated on ChromID extended spectrum β-lactamase plates and members of Enterobacteriaceae family were subjected to antibiotic susceptibility as per the Clinical Laboratory Standards Institute guidelines. Polymerase chain reaction for blaVIM, blaKPC, blaIMPand blaNDM-1 genes was performed. CRE was identified if the isolates showed resistance to either imipenem or meropenem or showed the presence of resistant genes. Risk factors of patients with or without CRE colonisation were also analysed. RESULTS A total of 232 faecal swabs yielded 252 Enterobacteriaceae isolates, of which 49 isolates from 42 patients showed the presence of CRE (occurrence 42/232; 18.1%); 27 isolates from 22 patients carried blaNDM-1, whereas 20 isolates from 17 patients possessed blaVIMgene. No isolate was positive for blaKPCand blaIMPgenes. The CRE was common in both intensive care units (38.4%) and wards (46%) which may reflect the excessive use of broad-spectrum antibiotics in both these settings. The CRE was also found to have a significantly higher antimicrobial resistance as compared to non-CRE isolates. The logistic regression analysis of significance showed the presence of any indwelling device (P = 0.049) and nasogastric tube (P = 0.043) as independent risk factors for acquiring gut colonisation. CONCLUSIONS The study is the first from India to show high CRE carriage in patients admitted to a tertiary care centre and emphasises the need of strict antimicrobial stewardship implementation in hospitals to prevent dissemination of multidrug-resistant CRE.
Collapse
Affiliation(s)
- Balvinder Mohan
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amber Prasad
- Department of Microbiology, RIMS, Ranchi, Jharkhand, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Neha Gautam
- Department of Microbiology, Dr. YS Parmar Government Medical College, Nahan, Himachal Pradesh, India
| | - Neelam Taneja
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
Zhang Y, Guo LY, Song WQ, Wang Y, Dong F, Liu G. Risk factors for carbapenem-resistant K. pneumoniae bloodstream infection and predictors of mortality in Chinese paediatric patients. BMC Infect Dis 2018; 18:248. [PMID: 29855274 PMCID: PMC5984460 DOI: 10.1186/s12879-018-3160-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 05/23/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSI) caused by carbapenem-resistant K. pneumoniae (CRKP) are associated with high rates of morbidity and mortality. Early identification of patients at highest risk is very important. The aim of this study was to describe the clinical characteristics and mortality of K. pneumoniae BSI and to identify risk factors associated with CRKP BSI among paediatric patients. METHODS From January 2011 to December 2014, a retrospective case-control study was conducted at Beijing Children's Hospital, China. Risk factors for CRKP BSI and for K. pneumoniae BSI-related death were evaluated. Patients with BSI caused by K. pneumoniae were identified from the microbiology laboratory database. Data regarding demographic, microbiological and clinical characteristics, therapy and outcome were collected from the medical records. RESULTS A total of 138 patients with K. pneumoniae BSI were enrolled, including 54 patients with CRKP BSI and 84 patients with carbapenem-susceptible K. pneumoniae (CSKP) BSI. Most of the BSI (114; 82.6%) were healthcare-associated, while the rest (24; 17.4%) were community-acquired. Hematologic malignancies (odds ratio (OR):4.712, [95% CI: 2.181-10.180], P < 0.001) and previous cephalosporin administration (OR: 3.427, [95% CI: 1.513-7.766], P = 0.003) were found to be associated with the development of CRKP BSI. 28-day mortality of K. pneumoniae BSI was 8.7%. Mechanical ventilation (OR:9.502, [95% CI: 2.098-43.033], P = 0.003), septic shock (OR:6.418, [95% CI: 1.342-30.686], P = 0.020), and isolation of CRKP (OR:9.171, [95% CI: 1.546-54.416], P = 0.015) were independent risk factors for 28-day mortality of K. pneumoniae BSI. CONCLUSION Hematologic malignancies and previous cephalosporin administration were associated with the development of CRKP BSI, while mechanical ventilation, septic shock and CRKP infection were independent mortality predictors for K. pneumoniae BSI. More attention should be paid to CRKP BSI in the paediatric population.
Collapse
Affiliation(s)
- Ye Zhang
- Department of Infectious Disease, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| | - Ling-Yun Guo
- Department of Infectious Disease, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| | - Wen-Qi Song
- Department of Laboratory Medicine, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| | - Yan Wang
- Department of Laboratory Medicine, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| | - Fang Dong
- Department of Laboratory Medicine, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| | - Gang Liu
- Department of Infectious Disease, Beijing Children’s Hospital, Capital Medical University, No. 56 Nanlishi Road, Xi Cheng District, Beijing, 100045 People’s Republic of China
| |
Collapse
|
18
|
Wang Y, Lei H, Zhang Y, Yang Q, Wang Y, Wang J, Xu C, Yu J, Zhou L, Kang X, Cui L. Epidemiology of carbapenem-resistant Klebsiella pneumoniae bloodstream infections after renal transplantation from donation after cardiac death in a Chinese hospital: a case series analysis. Antimicrob Resist Infect Control 2018; 7:66. [PMID: 29942492 PMCID: PMC5963103 DOI: 10.1186/s13756-018-0355-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/01/2018] [Indexed: 01/12/2023] Open
Abstract
Background Although the high mortality rates have been extensively reported worldwide, few studies have investigated the epidemiology of CRKP-BSIs in the early stage after kidney transplantation (KTx) from donation after cardiac death (DCD). We sought to describe the epidemiological and clinical characteristics of cases of carbapenem resistant Klebsiella pneumoniae bloodstream infections (CRKP-BSIs) in kidney transplantation recipients (KTRs) from DCD in our hospital. Methods A retrospective analysis of clinical data of CRKP-BSIs in KTRs admitted to a Chinese hospital in Beijing, China, between January 1, 2012 and December 31, 2016 was performed. The annual percentage of patients with CRKP, the annual number of total KTRs and KTRs from DCD were determined. The genetic relatedness of the strains was determined by polymerase chain reaction and pulse field gel electrophoresis (PFGE). Results During the study period, there were total 947 KTRs in our hospital, including 275 KTRs from DCD. Five incidences of CRKP-BSIs in KTRs were identified, and two of them (Case 1,3) from the same foreign hospital. The incidence of CRKP-BSIs in the early stage (within 3 months) following kidney transplantation (KTx) from DCD was about 1.1% (3/275). In Case 1–3 and 5, the rupture of renal transplant artery was presented on the 40th, 16th, 43th and 74th day after KTx, and in Case 4, the thrombus of renal transplant artery was presented on the 13th day after KTx. Three cases (Case 1,2,5) occurring pneumothorax on the 45th, 51th and 32th day after KTx. Four cases (Case 1–4) received the excision of the transplanted kidney for the treatment. Polymerase chain reaction showed the bands for case 2 were distinctive from other cases. Pulse field gel electrophoresis showed mainly three clusters of the bands for all the isolates. Conclusions During the study period, we observed an increase in the occurrence of CRKP-BSIs among KTRs from DCD in our hospital. We demonstrated that rupture/thrombus of the renal transplant artery was associated with CRKP-BSI in the early stage after KTx from DCD. Albeit the low incidence of CRKP-BSI (1.1%) after KTx from DCD, the high mortality (4/5) had been observed from the prognosis of the patients. Thorough surveillance of DCD donors, early identification of CRKP-BSI, necessary preventative measurements and use of appropriate treatments should be the strategy for CRKP-BSI in the early stage after KTx from DCD. Electronic supplementary material The online version of this article (10.1186/s13756-018-0355-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yuxi Wang
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Hong Lei
- 3Department of clinical laboratory, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Yuxiang Zhang
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Qiwen Yang
- 2Department of clinical laboratory, Peking Union Medical College Hospital, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730 China
| | - Yu Wang
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Jiaxing Wang
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Cheng Xu
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Jinggang Yu
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Lili Zhou
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Xiaoni Kang
- 1Department of Intensive Care Unit, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| | - Lei Cui
- 3Department of clinical laboratory, 309th hospital of Chinese People of Liberation of Army (PLA), No. 17 Heishanhu Road, Haidian District, Beijing, 100091 China
| |
Collapse
|
19
|
Liu P, Li X, Luo M, Xu X, Su K, Chen S, Qing Y, Li Y, Qiu J. Risk Factors for Carbapenem-Resistant Klebsiella pneumoniae Infection: A Meta-Analysis. Microb Drug Resist 2018; 24:190-198. [PMID: 28749714 PMCID: PMC5873294 DOI: 10.1089/mdr.2017.0061] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has been rapidly emerging as a life-threatening nosocomial disease in many countries. However, studies on the corresponding risk factors of CRKP infection showed inconsistent results. To resolve these inconsistencies, we conducted a meta-analysis of previous studies on the potential risk factors of CRKP infection. The results of this study could be used to develop CRKP infection prevention strategies. METHODS Relevant works were systematically searched from five electronic databases up to September 2016. Z-test was used to determine the significance of the pooled odds ratios (ORs). ORs and 95% confidence intervals were utilized to compare the risk factors of CRKP infection. RESULTS Sixteen studies that involved 3,627 participants were included in the meta-analysis. We identified the following risk factors that were associated with CRKP infection: (1) longer length of hospital stay (LOS) (OR = 12.92), (2) admission to intensive care unit (ICU) (OR = 2.48), (3) prior hospitalization (OR = 1.85), (4) longer days of ICU stay (OR = 4.58), (5) transplant recipient (OR = 2.01), (6) steroid use (OR = 1.43), (7) central venous catheter use (OR = 2.30), (8) mechanical ventilation (OR = 2.54), (9) presence of tracheostomy (OR = 3.63), (10) parenteral nutrition (OR = 2.38), (11) previous antibiotic use (OR = 3.31), and (12) exposure to carbapenems (OR = 4.01), (13) aminoglycosides (OR = 2.05), (14) glycopeptides (OR = 2.40), (15) quinolones (OR = 2.28), and (16) anti-pseudomonal penicillins (OR = 2.67). CONCLUSIONS Sixteen risk factors including longer LOS, admission to ICU, previous antibiotic use, and exposure to carbapenems were associated with the development of CRKP infection. Identification of modifiable risk factors could play an important role in the prevention of CRKP infection.
Collapse
Affiliation(s)
- Pin Liu
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Xuan Li
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Mei Luo
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Xuan Xu
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Kewen Su
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Shuai Chen
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Ying Qing
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Yingli Li
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| | - Jingfu Qiu
- School of Public Health and Management, Chongqing Medical University , Chongqing, China
| |
Collapse
|
20
|
Marimuthu K, Venkatachalam I, Khong WX, Koh TH, Cherng BPZ, Van La M, De PP, Krishnan PU, Tan TY, Choon RFK, Pada SK, Lam CW, Ooi ST, Deepak RN, Smitasin N, Tan EL, Lee JJ, Kurup A, Young B, Sim NTW, Thoon KC, Fisher D, Ling ML, Peng BAS, Teo YY, Hsu LY, Lin RTP, Ong RTH, Teo J, Ng OT. Clinical and Molecular Epidemiology of Carbapenem-Resistant Enterobacteriaceae Among Adult Inpatients in Singapore. Clin Infect Dis 2018; 64:S68-S75. [PMID: 28475792 DOI: 10.1093/cid/cix113] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Since 2010, the incidence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing in Singapore. We analyzed the clinical and molecular epidemiology of CRE among adult inpatients in Singapore. Methods Quarterly incidence of unique subjects (per 100000 patient-days) with positive clinical and surveillance cultures for CRE were estimated based on mandatory data submitted to the National Public Health Laboratory by public hospitals between 2010 and 2015. CRE-positive adult inpatients were prospectively recruited from 6 public sector hospitals between December 2013 and April 2015. Subjects answered a standardized epidemiologic questionnaire and provided samples for this study. Further clinical information was extracted from subjects' electronic medical records. Whole-genome sequencing was performed on study isolates to determine transmission clusters. Results Incidence of CRE clinical cultures among adult inpatients plateaued from 2013 (range: 7.73 to 10.32 per 100000 patient-days) following an initial increase between 2010 and end-2012. We prospectively recruited 249 subjects. Their median age was 65 years, 108 (43%) were female, and 161 (64.7%) had carbapenemase-producing Enterobacteriaceae (CPE). On multivariate analysis, prior carbapenem exposure (OR: 3.23; 95% CI: 1.67-6.25) and hematological malignancies (OR: 2.85; 95% CI: 1.10-7.41) were associated with non-carbapenemase-producing CRE (NCPE) (n = 88) compared with CPE (n = 161) subjects. Among 430 CRE isolates from the 249 subjects, 307(71.3%) were CPE, of which 154(50.2%) were blaKPC-positive, 97(31.6%) blaNDM-positive, and 42 (13.7%) blaOXA-positive. Klebsiella pneumoniae (n = 180, 41.9%), Escherichia coli (n = 129, 30.0%) and Enterobacter cloacae (n = 62, 14.4%) were the main Enterobacteriaceae species. WGS (n = 206) revealed diverse bacterial strain type (STs). The predominant blaKPC-positive plasmid was pHS102707 (n = 62, 55.4%) and the predominant blaNDM-positive plasmid was pNDM-ECS01 (n = 46, 48.9%). Five transmission clusters involving 13 subjects were detected. Conclusions Clinical CRE trend among adult inpatients showed stabilization following a rapid rise since introduction in 2010 potentially due to infection prevention measures and antimicrobial stewardship. More work is needed on understanding CPE transmission dynamics.
Collapse
Affiliation(s)
- Kalisvar Marimuthu
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore
| | | | - Wei Xin Khong
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | | | | | - My Van La
- National Public Health Laboratory, Ministry of Health of Singapore
| | - Partha Pratim De
- Department of Laboratory Medicine, Tan Tock Seng Hospital.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Prabha Unny Krishnan
- National Public Health Laboratory, Ministry of Health of Singapore.,Department of Laboratory Medicine, Tan Tock Seng Hospital.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Thean Yen Tan
- Department of Laboratory Medicine, Changi General Hospital, Singapore
| | - Raymond Fong Kok Choon
- Division of Infectious Diseases, Department of Medicine, Changi General Hospital, Singapore
| | - Surinder Kaur Pada
- Department of Infectious Diseases, Ng Teng Fong General Hospital, Singapore
| | - Choong Weng Lam
- Department of Laboratory Medicine, Ng Teng Fong General Hospital, Singapore
| | - Say Tat Ooi
- Department of Infectious Diseases, Khoo Teck Puat Hospital, Singapore
| | | | - Nares Smitasin
- Division of Infectious Diseases, National University Hospital, Singapore
| | - Eng Lee Tan
- Centre of Biomedical and Life Sciences, Singapore Polytechnic
| | - Jia Jun Lee
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | | | - Barnaby Young
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Nancy Tee Wen Sim
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore
| | - Koh Cheng Thoon
- Yong Loo Lin School of Medicine, National University of Singapore.,Department of Pediatrics, KK Women's and Children's Hospital, Singapore
| | - Dale Fisher
- Yong Loo Lin School of Medicine, National University of Singapore.,Division of Infectious Diseases, National University Hospital, Singapore
| | - Moi Lin Ling
- Department of Infection Prevention and Control, Singapore General Hospital
| | - Brenda Ang Sze Peng
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Yik-Ying Teo
- Centre for Infectious Disease Epidemiology and Research, Saw Swee Hock School of Public Health, National University of Singapore.,NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Centre for Life Sciences (CeLS).,Department of Statistics & Applied Probability, Faculty of Science, National University of Singapore.,Life Sciences Institute, National University of Singapore.,Genome Institute of Singapore
| | - Li Yang Hsu
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Saw Swee Hock School of Public Health, National University Health System
| | - Raymond Tzer Pin Lin
- National Public Health Laboratory, Ministry of Health of Singapore.,Department of Laboratory Medicine, National University Hospital, Singapore
| | - Rick Twee-Hee Ong
- Centre for Infectious Disease Epidemiology and Research, Saw Swee Hock School of Public Health, National University of Singapore
| | - Jeanette Teo
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Oon Tek Ng
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | |
Collapse
|
21
|
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: 143] [Impact Index Per Article: 23.8] [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.
Collapse
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
| |
Collapse
|
22
|
Freire MP, Oshiro ICVS, Pierrotti LC, Bonazzi PR, de Oliveira LM, Song ATW, Camargo CH, van der Heijden IM, Rossi F, Costa SF, DʼAlbuquerque LAC, Abdala E. Carbapenem-Resistant Enterobacteriaceae Acquired Before Liver Transplantation: Impact on Recipient Outcomes. Transplantation 2017; 101:811-820. [PMID: 28009779 DOI: 10.1097/tp.0000000000001620] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) is an emergent microorganism of infections after liver transplant (LT). The aim of this study was to analyze the risk factors for CRE acquisition and infection after LT. METHODS This was a prospective cohort study involving patients who underwent LT in the 2010 to 2014 period. Surveillance cultures for CRE were collected immediately before LT and weekly thereafter until hospital discharge. RESULTS We analyzed 386 patients undergoing a total of 407 LTs. Before LT, 68 (17.6%) patients tested positive for CRE, 11 (16.2%) of those patients having CRE infection, whereas 119 (30.8%) patients acquired CRE after LT. Post-LT CRE infection was identified in 59 (15.7%) patients: Klebsiella pneumoniae was isolated in 83.2%; surgical site infection was the most common type of infection (46.7%). Multivariate analysis showed that post-LT dialysis was the only risk factor for post-LT CRE acquisition. Eighty-two percent of patients who underwent 3 or more post-LT dialysis sessions and acquired CRE before LT evolved with post-LT CRE infection. Other risk factors for CRE infection were acquisition of CRE post-LT, Model for End-Stage Liver Disease score greater than 32, combined transplantation, and reoperation. Patients who acquired CRE before LT had a high risk of developing CRE infection (P < 0.001). CONCLUSIONS Measures for minimizing that risk, including altering the antibiotic prophylaxis, should be investigated and implemented.
Collapse
Affiliation(s)
- Maristela Pinheiro Freire
- 1 Infection Control Team, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil. 2 Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil. 3 Liver and Intestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil. 4 Microbiology Research Laboratory-LIM54, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil. 5 Centro de Bacteriologia, Instituto Adolfo Lutz, São Paulo, Brazil. 6 Microbiology Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Modifiable Risk Factors for the Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae Among Long-Term Acute-Care Hospital Patients. Infect Control Hosp Epidemiol 2017; 38:670-677. [PMID: 28397615 DOI: 10.1017/ice.2017.62] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients. DESIGN Multicenter, matched case-control study. SETTING Four LTACHs in Chicago, Illinois. PARTICIPANTS Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay. RESULTS From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01-1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06-4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01-1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure. CONCLUSIONS Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population. Infect Control Hosp Epidemiol 2017;38:670-677.
Collapse
|
24
|
Lee HJ, Choi JK, Cho SY, Kim SH, Park SH, Choi SM, Lee DG, Choi JH, Yoo JH. Carbapenem-resistant Enterobacteriaceae: Prevalence and Risk Factors in a Single Community-Based Hospital in Korea. Infect Chemother 2016; 48:166-173. [PMID: 27659436 PMCID: PMC5047997 DOI: 10.3947/ic.2016.48.3.166] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/18/2016] [Accepted: 09/02/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) are Gram-negative bacteria with increasing prevalence of infection worldwide. In Korea, 25 cases of CPE isolates were reported by the Korea Centers for Disease Control and Prevention in 2011. Most CPE cases were detected mainly at tertiary referral hospitals. We analyzed the prevalence and risk factors for carbapenem-resistant Enterobacteriaceae (CRE) in a mid-sized community-based hospital in Korea. MATERIALS AND METHODS We retrospectively analyzed all consecutive episodes of Enterobacteriaceae in a mid-sized community-based hospital from January 2013 to February 2014. CRE was defined as organisms of Enterobacteriaceae showing decreased susceptibility to carbapenems. Risk factors for CRE were evaluated by a case-double control design. Carbapenemase was confirmed for CRE using a combined disc test. RESULTS During 229,710 patient-days, 2,510 Enterobacteriaceae isolates were obtained. A total of 41 (1.6%) CRE isolates were enrolled in the study period. Thirteen species (31.7%) were Enterobacter aerogenes, 8 (19.5%) Klebsiella pneumoniae, 5 (12.2%) Enterobacter cloacae, and 15 other species of Enterobacteriaceae, respectively. Among the 41 isolates, only one (2.4%) E. aerogenes isolate belonged to CPE. For evaluation of risk factors, a total of 111 patients were enrolled and this included 37 patients in the CRE group, 37 in control group I (identical species), and 37 in control group II (different species). Based on multivariate analysis, regularly visiting the outpatient clinic was a risk factor for CRE acquisition in the control group I (P = 0.003), while vascular catheter and Charlson comorbidity index score ≥ 3 were risk factors in control group II (P = 0.010 and 0.011, each). Patients with CRE were more likely to experience a reduced level of consciousness, use a vasopressor, be under intensive care, and suffer from acute kidney injury. However, CRE was not an independent predictor of mortality compared with both control groups. CONCLUSION In conclusion, the prevalence of CRE was higher than expected in a mid-sized community-based hospital in Korea. CRE should be considered when patients have a vascular catheter, high comorbidity score, and regular visits to the outpatient clinic. This study suggests the need for appropriate prevention efforts and constant attention to CRE infection control in a mid-sized community-based hospital.
Collapse
Affiliation(s)
- Hyo Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Ki Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si Hyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hyun Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Hong Yoo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| |
Collapse
|
25
|
Risk Factors for Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) Acquisition Among Contacts of Newly Diagnosed CP-CRE Patients. Infect Control Hosp Epidemiol 2016; 37:1219-25. [PMID: 27452597 DOI: 10.1017/ice.2016.153] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) are extremely drug-resistant pathogens. Screening of contacts of newly identified CP-CRE patients is an important step to limit further transmission. We aimed to determine the risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient. METHODS A matched case-control study was performed in a tertiary care hospital in Israel. The study population was comprised of patients who underwent rectal screening for CP-CRE following close contact with a newly identified CP-CRE index patient. Cases were defined as positive tests for CP-CRE. For each case patient, 2 matched controls were randomly selected from the pool of contacts who tested negative for CP-CRE following exposure to the same index case. Bivariate and multivariate analyses were conducted using conditional logistic regression. RESULTS In total, 53 positive contacts were identified in 40 unique investigations (896 tests performed on 735 contacts) between October 6, 2008, and June 7, 2012. bla KPC was the only carbapenemase identified. In multivariate analysis, risk factors for CP-CRE acquisition among contacts were (1) contact with an index patient for ≥3 days (odds ratio [OR], 9.8; 95% confidence interval [CI], 2.0-48.9), (2) mechanical ventilation (OR, 4.1; 95% CI, 1.4-11.9), and (3) carriage or infection with another multidrug-resistant organism (MDRO; OR, 2.6; 95% CI, 1.0-7.1). Among patients who received antibiotics, cephalosporins were associated with a lower risk of acquisition. CONCLUSIONS Patient characteristics (ventilation and carriage of another MDRO) as well as duration of contact are risk factors for CP-CRE acquisition among contacts. The role of cephalosporins requires further study. Infect Control Hosp Epidemiol 2016;1-7.
Collapse
|
26
|
Freire MP, de Oliveira Garcia D, Cury AP, Spadão F, Di Gioia TSR, Francisco GR, Bueno MFC, Tomaz M, de Paula FJ, de Faro LB, Piovesan AC, Rossi F, Levin AS, David Neto E, Nahas WC, Pierrotti LC. Outbreak of IMP-producing carbapenem-resistant Enterobacter gergoviae among kidney transplant recipients. J Antimicrob Chemother 2016; 71:2577-85. [PMID: 27197663 DOI: 10.1093/jac/dkw165] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/07/2016] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES The objective of this study was to investigate a prolonged outbreak of carbapenem-resistant Enterobacter gergoviae (CREG) involving kidney transplant recipients (KTRs) between 2009 and 2014. METHODS A case-control study was undertaken. Controls (n = 52) were selected from CREG-negative KTRs. Surveillance cultures for CREG were collected weekly. Colonization was defined as isolation of CREG from surveillance samples or from clinical specimens, with no evidence of infection. We also investigated infection control practices at the facility. RESULTS Of 26 identified cases, 13 had had no known contact with another CREG-positive patient before the first positive culture. Seven patients (27%) developed infection. The site most often colonized was the urinary tract. During the study period two clusters were identified, one in 2009 and another in 2013-14. DNA sequencing revealed blaIMP-1 in all CREG tested. No environmental or hand cultures tested positive for CREG. An audit of infection control practices detected flaws in the handling and cleaning of urinary tract devices. Multivariate analysis identified advanced age, ureteral stent use, retransplantation and male gender as risk factors for CREG acquisition. CONCLUSIONS An outbreak among KTRs caused by an unusual species of MDR bacteria may have resulted from a common source of contamination related to urinary tract devices.
Collapse
Affiliation(s)
- Maristela Pinheiro Freire
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | | | - Ana Paula Cury
- Microbiology Section, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Fernanda Spadão
- Working Committee for Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | | | | | | | - Mariama Tomaz
- Laboratory for Medical Research 54, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Flavio Jota de Paula
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | | | - Affonso C Piovesan
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Flavia Rossi
- Microbiology Section, Central Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Anna Sara Levin
- Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Elias David Neto
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - William C Nahas
- Renal Transplantation Unit, Department of Urology, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Ligia Camera Pierrotti
- Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil
| |
Collapse
|
27
|
Healthcare-associated infections due to carbapenemase-producing Enterobacteriaceae: Bacteriological profile and risk factors. Med Mal Infect 2016; 46:157-62. [DOI: 10.1016/j.medmal.2015.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/12/2015] [Accepted: 12/17/2015] [Indexed: 11/20/2022]
|
28
|
Maseda E, Salgado P, Anillo V, Ruiz-Carrascoso G, Gómez-Gil R, Martín-Funke C, Gimenez MJ, Granizo JJ, Aguilar L, Gilsanz F. Risk factors for colonization by carbapenemase-producing enterobacteria at admission to a Surgical ICU: A retrospective study. Enferm Infecc Microbiol Clin 2016; 35:333-337. [PMID: 27016135 DOI: 10.1016/j.eimc.2016.02.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/11/2016] [Accepted: 02/21/2016] [Indexed: 12/28/2022]
Abstract
INTRODUCTION In 2011, a hospital-wide outbreak of OXA-48 producing Klebsiella pneumoniae occurred in our hospital, an epidemiological setting of high ESBL-producing K. pneumoniae rates. This study identifies risk factors for colonization with carbapenemase-producing enterobacteria (CPE) at Surgical Intensive Care Unit (SICU) admission. METHODS A 2-year retrospective study was performed in all patients admitted to the SICU that following routine had a rectal swab collected upon admission. RESULTS Of 254 patients admitted, 41 (16.1%) harbored CPE (five showing two carbapenemase-producing isolates). Most frequent carbapenemase-producing isolates and carbapenemases were K. pneumoniae (39/46, 84.8%) and OXA-48 (31/46; 76.1%), respectively. Carriers significantly had higher rates of chronic renal disease, previous digestive/biliary endoscopy, hospitalization, ICU/SICU admission, intraabdominal surgery, and antibiotic intake, as well as higher median values of clinical scores (SOFA, SAPS II and APACHE II). In the multivariate analysis (R2=0.309, p<0.001), CPE carriage was associated with prior administration of 3rd-4th generation cephalosporins (OR=27.96, 95%CI=6.88, 113.58, p<0.001), β-lactam/β-lactamase inhibitor (OR=11.71, 95%CI=4.51, 30.43, p<0.001), abdominal surgery (OR=6.33, 95%CI=2.12, 18.89, p=0.001), and prior digestive/biliary endoscopy (OR=3.88, 95%CI=1.56, 9.67, p=0.004). CONCLUSIONS A strong association between production of ESBLs and carriage of CPE (mainly OXA-48 producing K. pneumoniae) was found. According to the model, the co-selection of β-lactamases by previous exposure to broad-spectrum cephalosporins and β-lactam/β-lactamase inhibitors (with lower relative risk), abdominal surgery and prior digestive/biliary endoscopy were factors associated with CPE carriage.
Collapse
Affiliation(s)
- Emilio Maseda
- Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario La Paz, Madrid, Spain.
| | - Patricia Salgado
- Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario La Paz, Madrid, Spain
| | - Víctor Anillo
- Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario La Paz, Madrid, Spain
| | | | - Rosa Gómez-Gil
- Microbiology Dpt., Hospital Universitario La Paz, Madrid, Spain
| | - Carmen Martín-Funke
- General Medicine Dpt., Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | - Fernando Gilsanz
- Anesthesiology and Surgical Critical Care Dpt., Hospital Universitario La Paz, Madrid, Spain
| |
Collapse
|
29
|
Peretz A, Pastukh N, Isakovich N, Koifman A, Brodsky D, Mizrahi H, Aharon I, Labay K. Efficacy of an Enrichment Media for Increasing Threshold for Carbapenem-Resistant Enterobacteriaceae Screening. J Clin Lab Anal 2015; 30:563-6. [PMID: 26666427 DOI: 10.1002/jcla.21903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 10/09/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Identification of carbapenem-resistant Enterobacteriaceae (CRE) is complex and a major laboratory challenge; clinical cultures may diagnose only some of the CRE carriers among patients, thus it is crucial to perform asymptomatic carriage screening. MATERIALS AND METHODS We compare the efficacy of a rectal sample culture prior to enrichment with BHI (Brain Heart Infusion) Broth and following 18-24 h. All rectal samples were applied on CHROMagar KPC selective growth media and then seeded on MacConkey agar selective growth media with an applied disk of Imipenem antibiotic on top of the media, then inserted into enrichment BHI Broth. After 18-24 h incubation with enrichment media, all samples were applied again on this media. RESULTS From the 2,245 rectal samples, CRE colonies were found in 96 (4.3%). Following enrichment with BHI Broth, CRE colonies were found in 111 (4.9%) CHROMagar KPC plates and 106 (4.7%) MacConkey agar. CONCLUSION We were able to demonstrate that the number of CRE-positive results increased due to use of additional enrichment with BHI Broth. Therefore, we recommend applying this method of addition of liquid enrichment media as part of a culture protocol routine for CRE screening.
Collapse
Affiliation(s)
- Avi Peretz
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel. .,Unit for Infectious Diseases, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel.
| | - Nina Pastukh
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Natlya Isakovich
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Anna Koifman
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Diana Brodsky
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Hila Mizrahi
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Ilana Aharon
- Unit for Infectious Diseases, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| | - Kozitta Labay
- Unit for Infectious Diseases, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty of Medicine, Bar Ilan University, Galilee, Israel
| |
Collapse
|
30
|
Ny P, Nieberg P, Wong-Beringer A. Impact of carbapenem resistance on epidemiology and outcomes of nonbacteremic Klebsiella pneumoniae infections. Am J Infect Control 2015; 43:1076-80. [PMID: 26190386 DOI: 10.1016/j.ajic.2015.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although high mortality associated with carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteremia has been well described, the epidemiology and outcomes of nonbacteremic infection are unknown. METHODS Medical charts of adults hospitalized for CRKP pneumonia or urinary tract infection between January 2011 and December 2013 were reviewed retrospectively for relevant demographic and clinical details. Cases were matched to controls (non-carbapenem-resistant, non-extended-spectrum beta-lactamase [ESBL]-producing K pneumoniae [NRKP]) by the primary site of infection and year of isolation and compared in terms of risk of acquisition and outcomes. RESULTS The CRKP and NRKP arms (n = 48 each) were elderly (median age, 74 years). Compared with controls, more patients in the CRKP arm resided in skilled nursing/long-term acute care facilities (77% vs 29%; P < .01), had a chronic tracheostomy (29% vs 0%; P < .001), decubitus ulcers (69% vs 17%; P < .01), higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (median, 21.5 vs 14; P = .02), and required intensive care unit admission (54% vs 31%; P = .04). More patients in the CRKP arm had previous ESBL infection (23% vs 6%; P = .04), and this arm had at least a 10-fold greater risk of coinfection with other carbapenem-resistant pathogens (44% vs 4%; P < .01), as well as a 7-fold greater likelihood of previous carbapenem therapy (23% vs 4%; P = .01). Patients in the CRKP arm had prolonged hospitalization (median, 13 days) and a 32% rate of readmission within 30 days of discharge. CONCLUSIONS CRKP nonbacteremic infections occur in debilitated patients and are associated with frequent previous carbapenem exposure and high resource utilization, underscoring the need to focus efforts on antimicrobial stewardship and infection control.
Collapse
|
31
|
Jiao Y, Qin Y, Liu J, Li Q, Dong Y, Shang Y, Huang Y, Liu R. Risk factors for carbapenem-resistant Klebsiella pneumoniae infection/colonization and predictors of mortality: a retrospective study. Pathog Glob Health 2015; 109:68-74. [PMID: 25707874 DOI: 10.1179/2047773215y.0000000004] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To identify risk factors associated with carbapenem-resistant Klebsiella pneumoniae (CRKP) infection/colonization and death and to investigate the resistance and homology of CRKP. METHODS A retrospective 1:1 case-control study was conducted at Changhai Hospital, China, from January 2010 to December 2011.The study population included 30 patients with CRKP infection/colonization and 30 matched patients with carbapenem-susceptible K. pneumoniae (CSKP) infection/colonization at the same site. Homology analysis was conducted by multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE). Potential resistance genes were detected by PCR. RESULTS Independent risk factors for CRKP infection/colonization were admission to exposure to glycopeptides [Odds ratio (OR): 43.84, 95% confidence interval (CI): 1.73-1111.91, P = 0.020], cefoperazone plus sulbactam (OR: 49.56, 95% CI: 1.42-1726.72, P = 0.030) and tracheostomy (OR: 677.82, 95% CI: 2.76-1667, P = 0.020). Age (OR: 1.07, 95% CI: 1.00-1.14, P = 0.04), renal dysfunction (OR: 17.63, 95% CI: 2.34-132.87, P = 0.005) and exposure to cefoperazone plus sulbactam (OR: 8.87, 95% CI: 1.29-61.07, P = 0.026) were independent risk factors for the death of patients with K. pneumoniae infection/colonization. Older age (OR: 1.16, 95% CI: 1.01-1.39, P = 0.011) was an independent risk factor for the death of patients with CRKP infection/colonization. Thirty CRKP strains were all KPC-2-producing resistant strains with genotype of ST-11. CONCLUSION Exposure to glycopeptides, cefoperazone plus sulbactam and tracheostomy were independent risk factors for CRKP infection/colonization, and older age was an independent risk factor for CRKP infection/colonization caused death.
Collapse
|
32
|
Risk factors and outcome of infections with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae in kidney transplant recipients. Infection 2015; 43:315-23. [PMID: 25690848 DOI: 10.1007/s15010-015-0743-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/02/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Solid organ transplant recipients are especially susceptible to healthcare-associated infections with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp-HAIs). The aim of the study was to evaluate risk factors and outcome of these infections in kidney transplant recipients. METHODS This was a retrospective cohort of kidney transplant (KTx) recipients between January 2009 and December 2013. Cases were defined as patients who developed KPC-Kp-HAI, confirmed by PCR for bla( KPC) gene after KTx during the study period. We analysed variables related to recipient; induction immunosuppressant therapy; delayed graft function; use of invasive devices; SOFA score on the first day of infection; type of therapy; time from positive culture to appropriate antimicrobial therapy; bacteraemia; and concomitant infection. Outcome measures were the occurrence of KPC-Kp-HAI and 30-day mortality after KPC-Kp-HAI. RESULTS A total of 1,101 were submitted to KTx in the period, 21 patients were classified as infected with KPC-Kp. Another ten patients had KPC-Kp-HAI in the period and were transplanted before 2009. Of those 31 patients, 48.4 % showed evidence of prior colonization and 38.7 % had bacteraemia. The most common site of infection was the surgical wound. Risk factors for KPC-Kp-HAI were multi-organ transplantation and the use of a ureteral stent. Eight of the infected patients experienced recurrence of the infection. The 30-day mortality rate was 41.9 %. Survival was significantly lower among the patients with KPC-Kp-HAI (72 vs. 89.1 %; P = 0.002). The only risk factor independently associated with 30-day mortality was an elevated SOFA score on the first day of infection. CONCLUSIONS In KTx recipients, the occurrence of KPC-Kp-HAI was related to invasive devices and type of transplant; these infections had a high rate of recurrence and reduced survival after KTx.
Collapse
|
33
|
Candevir Ulu A, Kurtaran B, Inal AS, Kömür S, Kibar F, Yapıcı Çiçekdemir H, Bozkurt S, Gürel D, Kılıç F, Yaman A, Aksu HSZ, Taşova Y. Risk factors of carbapenem-resistant Klebsiella pneumoniae infection: a serious threat in ICUs. Med Sci Monit 2015; 21:219-24. [PMID: 25595166 PMCID: PMC4304439 DOI: 10.12659/msm.892516] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Nosocomial infections caused by Carbapenem-resistant Klebsiella pneumoniae (CRKP) are increasing. Our aim in this study was to investigate the risk factors of CRKP infections. Material/Methods A retrospective cohort study was performed between 1 January and 31 December 2012 in ICU patients. Data was taken from the hospital infection control database for CRKP. The clinical samples collected from the patients were tested by an automatized system and disk diffusion. SPSS software v11.5 was used for statistical analysis. Results Totally, 105 Klebsiella pneumoniae isolates were found in 2012 and the carbapenem resistance rate was 48%. The first episode of infection was taken into risk factor analysis. Of the 98 patients, 61 (62.2%) were male and the mean and median ages were 30.4±29.8 and 25 (0–93). The length of stay was longer in the resistant group (p=0.026). Mortality was 48% in the whole group and similar between groups (p=0.533). There was a relationship between meropenem and third-generation cephalosporin use and resistance (OR 3.244 (1.193–8.819) and OR: 3.590 (1.056–12.209). The other risk factors in univariate analysis were: Immunosuppression OR: 2.186 (1.754–2.724), nasogastric catheter OR: 3.562 (1.317–9.634), peripheral arterial catheter OR: 2.545 (1.027–6.307), and being admitted to the neurosurgical unit OR: 4.324 (1.110–16.842). The multivariate analysis showed use of third-generation cephalosporin OR: 4.699 (1.292–17.089), nasogastric catheter use OR: 3.983 (1.356–11.698), and being admitted to neurosurgical ICU OR: 4.603 (1.084–19.555) as independent risk factors. Conclusions Restriction of third-generation cephalosporin and carbapenem use and invasive procedures, along with infection control precautions and disinfection policies, may be effective in reducing the carbapenem resistance in ICUs.
Collapse
Affiliation(s)
| | - Behice Kurtaran
- Department of Infectious, Çukurova University, Adana, Turkey
| | - Ayşe Seza Inal
- Department of Infectious Diseases, Çukurova University, Adana, Turkey
| | - Süheyla Kömür
- Department of Infectious Diseases, Çukurova University, Adana, Turkey
| | - Filiz Kibar
- Department of Microbiology, Çukurova University, Adana, Turkey
| | | | - Seval Bozkurt
- Department of Infection Control Commitee, Çukurova University, Adana, Turkey
| | - Derya Gürel
- Department of Infection Control Commitee, Çukurova University, Adana, Turkey
| | - Fatma Kılıç
- Department of Infection Control Commitee, Çukurova University, Adana, Turkey
| | - Akgün Yaman
- Department of Microbiology, Çukurova University, Adana, Turkey
| | | | - Yeşim Taşova
- Department of Infectious Diseases, Çukurova University, Adana, Turkey
| |
Collapse
|
34
|
Hyle EP, Ferraro MJ, Silver M, Lee H, Hooper DC. Ertapenem-Resistant Enterobacteriaceae Risk Factors for Acquisition and Outcomes. Infect Control Hosp Epidemiol 2015; 31:1242-9. [DOI: 10.1086/657138] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background and Objective.Carbapenem resistance among Enterobacteriaceae is of concern because of increasing prevalence and limited therapeutic options. Limited research has been focused on understanding ertapenem resistance as a more sensitive marker for resistance to other carbapenems. We sought to determine risk factors for acquisition of ertapenem-resistant, meropenem-susceptible, or intermediate Enterobacteriaceae and to assess associated patient outcomes.Design.Retrospective case-control study among adult hospitalized inpatients.Setting.A 902-bed quaternary care urban hospital.Results.Sixty-two cases of ertapenem-resistant Enterobacteriaceae were identified from March 14, 2006, through October 31, 2007, and 62 unmatched control patients were randomly selected from other inpatients with cultures positive for ertapenem-susceptible Enterobacteriaceae. Thirty-seven (60%) of case patient isolates were Enterobacter cloacae, 20 (32%) were Klebsiella pneumoniae, and 5 (8%) were other species of Enterobacteriaceae. Risk factors for ertapenem-resistant Enterobacteriaceae infection included intensive care unit stay (odds ratio [OR], 4.6 [95% confidence interval {CI}, 2.0–10.3]), vancomycin-resistant Enterococcus colonization (OR, 7.1 [95% CI, 2.4–21.4]), prior central venous catheter use (OR, 10.0 [95% CI, 3.0–33.1]), prior receipt of mechanical ventilation (OR, 5.8 [95% CI, 2.1–16.2]), exposure to any antibiotic during the 30 days prior to a positive culture result (OR, 18.5 [95% CI, 4.9–69.9]), use of a β-lactam during the 30 days prior to a positive culture result (OR, 6.9 [95% CI, 3.0–16.0], and use of a carbapenem during the 30 days prior to a positive culture result (OR, 18.2 [95% CI, 2.6–130.0]). For the 62 case patients, 30-day outcomes from the time of positive culture result were 24 discharges (39%), 10 deaths (16%), and 28 continued hospitalizations (44%). The final end point of the hospitalization was discharge for 44 patients (71%) and death for 18 patients (29%).Conclusions.Ertapenem-resistant Enterobacteriaceae are important nosocomial pathogens. Multiple mechanisms of resistance maybe in operation. Additional study of ertapenem resistance is needed.
Collapse
|
35
|
Schechner V, Kotlovsky T, Tarabeia J, Kazma M, Schwartz D, Navon-Venezia S, Carmeli Y. Predictors of Rectal Carriage of Carbapenem-Resistant Enterobacteriaceae (CRE) among Patients with Known CRE Carriage at Their Next Hospital Encounter. Infect Control Hosp Epidemiol 2015; 32:497-503. [DOI: 10.1086/659762] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background.Carbapenem-resistant Enterobacteriaceae (CRE) are important extremely drug-resistant pathogens that have emerged during the past decade. Early identification and isolation of carriers are key components of an effective infection control strategy in healthcare facilities. Very little is known about the natural history of CRE carriage. We aimed to determine the predictors of a positive CRE rectal screen test among patients with known CRE carriage screened at their next hospital encounter.Methods.A case-control study was conducted. Sixty-six patients who tested positive for CRE carriage were surveyed for CRE rectal carriage at the next hospital encounter; screen-positive patients were compared with screen-negative control patients. Data were extracted from the patients' medical records and from the hospital computerized database.Results.Twenty-three case patients and 43 control patients were identified. Predictors for a positive CRE rectal carriage test were (1) prior fluoroquinolone use (odds ratio [OR], 4.27; 95% confidence interval [CI], 1.10–16.6), (2) admission from an institution or another hospital (OR, 4.04; 95% CI, 1.33–12.37), and (3) time interval less than or equal to 3 months since the first positive CRE test (OR, 3.59; 95% CI, 1.24–10.37). Among patients with no predictor variables, the likelihood of having a positive screen test at the next hospital encounter was 1/7. If they had at least 1 predictor, the likelihood increased to 1/2.Conclusions.Prior fluoroquinolone use, transfer from another healthcare facility, and admission less than or equal to 3 months since the first CRE isolation are predictors of persistent CRE rectal carriage. These predictors can be used in designing CRE prevention strategies.
Collapse
|
36
|
Gregory CJ, Llata E, Stine N, Gould C, Santiago LM, Vazquez GJ, Robledo IE, Srinivasan A, Goering RV, Tomashek KM. Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Puerto Rico Associated with a Novel Carbapenemase Variant. Infect Control Hosp Epidemiol 2015; 31:476-84. [DOI: 10.1086/651670] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background.Carbapenem-resistantKlebsiella pneumoniae(CRKP) is resistant to almost all antimicrobial agents, and CRKP infections are associated with substantial morbidity and mortality.Objective.To describe an outbreak of CRKP in Puerto Rico, determine risk factors for CRKP acquisition, and detail the successful measures taken to control the outbreak.Design.Two case-control studies.Setting.A 328-bed tertiary care teaching hospital.Patients.Twenty-six CRKP case patients identified during the outbreak period of February through September 2008, 26 randomly selected uninfected control patients, and 26 randomly selected control patients with carbapenem-susceptibleK. pneumoniae(CSKP) hospitalized during the same period.Methods.We performed active case finding, including retrospective review of the hospital's microbiology database and prospective perirectal surveillance culture sampling in high-risk units. Case patients were compared with each control group while controlling for time at risk. We sequenced theblaKPCgene with polymerase chain reaction for 7 outbreak isolates and subtyped these isolates with pulsed-field gel electrophoresis.Results.In matched, multivariable analysis, the presence of wounds (hazard ratio, 19.0 [95% confidence interval {CI}, 2.5-142.0]) was associated with CRKP compared with noK. pneumoniae.Transfer between units (adjusted odds ratio [OR], 7.5 [95% CI, 1.8-31.1]), surgery (adjusted OR, 4.0 [95% CI, 1.0-15.7]), and wounds (adjusted OR, 4.9 [95% CI, 1.1-21.8]) were independent risk factors for CRKP compared to CSKP. A novelK. pneumoniaecarbapenemase variant (KPC-8) was present in 5 isolates. Implementation of active surveillance for CRKP colonization and cohorting of CRKP patients rapidly controlled the outbreak.Conclusions.Enhanced surveillance for CRKP colonization and intensified infection control measures that include limiting the physical distribution of patients can reduce CRKP transmission during an outbreak.
Collapse
|
37
|
Bhargava A, Hayakawa K, Silverman E, Haider S, Alluri KC, Datla S, Diviti S, Kuchipudi V, Muppavarapu KS, Lephart PR, Marchaim D, Kaye KS. Risk factors for colonization due to carbapenem-resistant Enterobacteriaceae among patients exposed to long-term acute care and acute care facilities. Infect Control Hosp Epidemiol 2014; 35:398-405. [PMID: 24602945 DOI: 10.1086/675614] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aimed to identify risk factors associated with carbapenem-resistant Enterobacteriaceae (CRE) colonization among patients screened with rectal cultures upon admission to a hospital or long-term acute care (LTAC) center and to compare risk factors among patients who were screen positive for CRE at the time of hospital admission with those screen positive prior to LTAC admission. METHODS A retrospective nested matched case-control study was conducted from June 2009 to December 2011. Patients with recent LTAC exposure were screened for CRE carriage at the time of hospital admission, and patients admitted to a regional LTAC facility were screened prior to LTAC admission. Cases were patients with a positive CRE screening culture, and controls (matched in a 3∶1 ratio to cases) were patients with negative screening cultures. RESULTS Nine hundred five cultures were performed on 679 patients. Forty-eight (7.1%) cases were matched to 144 controls. One hundred fifty-eight patients were screened upon hospital admission and 521 prior to LTAC admission. Independent predictors for CRE colonization included Charlson's score greater than 3 (odds ratio [OR], 4.85 [95% confidence interval (CI), 1.64-14.41]), immunosuppression (OR, 3.92 [95% CI, 1.08-1.28]), presence of indwelling devices (OR, 5.21 [95% CI, 1.09-2.96]), and prior antimicrobial exposures (OR, 3.89 [95% CI, 0.71-21.47]). Risk factors among patients screened upon hospital admission were similar to the entire cohort. Among patients screened prior to LTAC admission, the characteristics of the CRE-colonized and noncolonized patients were similar. CONCLUSIONS These results can be used to identify patients at increased risk for CRE colonization and to help target active surveillance programs in healthcare settings.
Collapse
Affiliation(s)
- Ashish Bhargava
- Division of Infectious Diseases, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Han SB, Jung SW, Bae EY, Lee JW, Lee DG, Chung NG, Jeong DC, Cho B, Kang JH, Kim HK, Park YJ. Extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae bacteremia in febrile neutropenic children. Microb Drug Resist 2014; 21:244-51. [PMID: 25398058 DOI: 10.1089/mdr.2014.0092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This retrospective study was conducted to evaluate clinical outcomes of bacteremia caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae and their antibiotic susceptibilities in febrile neutropenic children. Clinical characteristics, prognosis, and antibiotic susceptibilities were reviewed and compared between febrile neutropenic children with bacteremia caused by ESBL-producing and non-ESBL-producing E. coli and K. pneumoniae. A total of 61 episodes of E. coli and K. pneumoniae bacteremia, including 21 episodes (34.4%) due to ESBL-producing strains, were diagnosed. There was no significant factor associated with bacteremia by ESBL-producing strains. Empirical antibiotics were appropriate in 85.7% of the ESBL group and 95.0% of the non-ESBL group. In the entire study population, seven deaths (11.5%), including three deaths (4.9%) due to E. coli and K. pneumoniae bacteremia, occurred. The complication and mortality rates were not significantly different between the two groups. Antibiotic susceptibility rates were significantly lower in the ESBL group than in the non-ESBL group in most antibiotics. Although 52.4% and 66.7% of the ESBL-producing isolates were susceptible to piperacillin/tazobactam and cefepime, respectively, 96.7% of all the isolates and 90.5% of the ESBL-producing isolates were susceptible to piperacillin/tazobactam or cefepime in combination with aminoglycoside. In conclusion, the ESBL group did not show a significantly unfavorable outcome, and empirical therapy with piperacillin/tazobactam or cefepime in combination with aminoglycoside might be more useful for febrile neutropenic children, instead of β-lactam monotherapy in institutions with high prevalence of ESBL-producing E. coli and K. pneumoniae.
Collapse
Affiliation(s)
- Seung Beom Han
- 1 Department of Pediatrics, College of Medicine, The Catholic University of Korea , Seoul, Republic of Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Lepeule R, Leflon-Guibout V, Vanjak D, Zahar JR, Lafaurie M, Besson C, Lefort A. Clinical spectrum of urine cultures positive for ESBL-producing Escherichia coli in hospitalized patients and impact on antibiotic use. Med Mal Infect 2014; 44:530-4. [PMID: 25311839 DOI: 10.1016/j.medmal.2014.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 08/04/2014] [Accepted: 09/10/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We wanted to describe the clinical features associated with urinalysis positive for ESBL-producing Escherichia coli and their impact on antibiotic use. METHODS We performed a prospective observational study in 13 French hospitals of the Paris area for 3 consecutive months. We included all patients with urine cultures positive for ESBL-producing E. coli. RESULTS One hundred and seventeen of the 218 patients (54%) presented with asymptomatic bacteriuria, 31 (14%) with cystitis, and 70 (32%) with a parenchymal infection. Nineteen patients with asymptomatic bacteriuria (16%) received antibiotics. Forty-one with parenchymal infections (59%) received a carbapenem. A carbapenem alternative could have been used in every patient treated with a carbapenem, according to antibiotic susceptibility testing results. CONCLUSIONS Urinary tract infections accounted for 46% of E. coli ESBL positive urinalysis. Fifty percent of parenchymal infections were treated with a carbapenem.
Collapse
Affiliation(s)
- R Lepeule
- Unité transversale de traitement des infections, département de virologie, bactériologie-hygiène, parasitologie-mycologie, hôpital Henri-Mondor, AP-HP, 94010 Créteil, France.
| | - V Leflon-Guibout
- Service de microbiologie, hôpital Beaujon, hôpitaux universitaires Paris Nord Val-de-Seine, AP-HP, Clichy, France
| | - D Vanjak
- Unité de contrôle des infections, institut Curie, Paris, France
| | - J-R Zahar
- Unité de prévention et de lutte contre les infections nosocomiales, CHU d'Angers - Université d'Angers, Angers, France
| | - M Lafaurie
- Unité d'intervention en infectiologie, hôpital Saint-Louis, AP-HP, Paris, France
| | - C Besson
- Service de microbiologie clinique, hôpital Européen Georges-Pompidou, AP-HP, Paris, France
| | - A Lefort
- Service de médecine interne, hôpital Beaujon, hôpitaux universitaires Paris Nord Val-de-Seine, AP-HP, Clichy, France; IAME, UMR1137, université Paris-Diderot, Sorbonne Paris Cité, Paris, France; EA3964, faculté de médecine Xavier-Bichat, université Paris-Diderot, Paris, France
| | | |
Collapse
|
40
|
Freire MP, Pierrotti LC, Filho HHC, Ibrahim KY, Magri ASGK, Bonazzi PR, Hajar L, Diz MPE, Pereira J, Hoff PM, Abdala E. Infection with Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae in cancer patients. Eur J Clin Microbiol Infect Dis 2014; 34:277-86. [DOI: 10.1007/s10096-014-2233-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/15/2014] [Indexed: 10/24/2022]
|
41
|
Ahn JY, Song JE, Kim MH, Choi H, Kim JK, Ann HW, Kim JH, Jeon Y, Jeong SJ, Kim SB, Ku NS, Han SH, Song YG, Yong D, Lee K, Kim JM, Choi JY. Risk factors for the acquisition of carbapenem-resistant Escherichia coli at a tertiary care center in South Korea: a matched case-control study. Am J Infect Control 2014; 42:621-5. [PMID: 24837112 DOI: 10.1016/j.ajic.2014.02.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/26/2014] [Accepted: 02/27/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Carbapenem resistance among gram-negative bacilli is an emerging threat worldwide. The objective of this study was to identify risk factors for the acquisition of carbapenem-resistant Escherichia coli (CRE). METHODS We conducted a matched case-control study comprising 57 cases of acquisition of CRE and 114 controls (1:2 matched) selected from patients with a culture of carbapenem-susceptible E coli between January 2006 and December 2010 at a 2000-bed tertiary care center in South Korea. RESULTS On univariate analysis, previous use of carbapenem (P < .01), fluoroquinolone (P < .01), and glycopeptide (P < .01), as well as length of hospital stay (P < .05), were significantly associated with CRE acquisition. On multivariate analysis, previous use of carbapenem (odds ratio [OR], 4.56; 95% confidence interval [CI] 1.44-14.46; P = .01) and previous use of fluoroquinolone (OR, 2.81; 95% CI, 1.14-6.99; P = .03) were independent risk factors. CONCLUSIONS At this institute, the antibiotic selective pressure of carbapenems and fluoroquinolones was shown to be an important risk factor for the acquisition of CRE.
Collapse
Affiliation(s)
- Jin Young Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Je Eun Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Hyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Heun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hea Won Ann
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yongduk Jeon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Bean Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dongeun Yong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea; AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
42
|
Zhao ZC, Xu XH, Liu MB, Wu J, Lin J, Li B. Fecal carriage of carbapenem-resistant Enterobacteriaceae in a Chinese university hospital. Am J Infect Control 2014; 42:e61-4. [PMID: 24773806 DOI: 10.1016/j.ajic.2014.01.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 01/23/2014] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) is widespread in China. To date, no study available has specifically determined the prevalence and risk factors of inpatients with CRE intestinal colonization in this region. METHODS Stool samples were screened for the presence of CRE in a Chinese university hospital. A case-control study was performed to identify risk factors associated with CRE fecal colonization. Case patients were those who had CRE colonization. Control subjects had no microbiologic evidence of CRE colonization. Clinical data were obtained from the medical record. RESULTS The prevalence of CRE was 6.6% (20/303 patients), of which 8 had carbapenemase-producing isolates. KPC-2, IMP-4, and NDM-1 were detected from these isolates. Hospital readmissions (odds ratio [OR], 58.067; 95% confidence interval [95% CI]: 5.517-611.134; P = .001), sickbed changes (OR, 45.904; 95% CI: 8.484-248.376; P < .001), invasive procedures (OR, 8.322; 95% CI: 1.996-34.690; P = .004), and vancomycin (OR, 11.552; 95% CI: 1.155-115.574; P = .037) were independently associated with CRE colonization. CONCLUSION This study demonstrated that asymptomatic intestinal carriage of CRE was relatively common in one region of China. Our study suggested that the implementation of effective infection control measures is urgently required to control the transmission of CRE in health care facilities in this country.
Collapse
|
43
|
Kofteridis DP, Valachis A, Dimopoulou D, Maraki S, Christidou A, Mantadakis E, Samonis G. Risk factors for carbapenem-resistant Klebsiella pneumoniae infection/colonization: a case-case-control study. J Infect Chemother 2014; 20:293-7. [PMID: 24703709 DOI: 10.1016/j.jiac.2013.11.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/07/2013] [Accepted: 11/09/2013] [Indexed: 11/30/2022]
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is increasingly reported worldwide. The aim of the present study was to identify risk factors associated with the development of CRKP infections. A retrospective, case-case-control study was performed at the University Hospital of Heraklion, Greece. The study population included 83 patients from whom CRKP was isolated, 79 from whom carbapenem-sensitive K. pneumoniae (CSKP) was isolated and 161 (control group) from whom K. pneumoniae was not isolated. The median age of CRKP and CSKP patients was 79 (28-101) and 80 (39-97) years, respectively, while that of the controls was 75 (18-100) years. K. pneumoniae was isolated predominantly from urine in both case groups, followed by blood. Independent risk factors for CRKP infection/colonization were admission to ICU (p = 0.004), prior surgical procedure (p = 0.036) and presence of renal disease (p = 0.037), while for CSKP were neurological disease (p = 0.007), and older age (p = 0.011). No association between CRKP and prior antimicrobial exposure was found. Of the entire cohort 40 patients (12%) died; 22 (27%) in the CRKP, 12 (15%) in the CSKP and 6 (4%) in the control group. Isolation of any K. pneumoniae strain was associated with higher mortality compared to the control group (21% vs. 4%; p < 0.005). Mortality was not statistically different between those infected/colonized/with a CRKP or a CSKP strain (p = 0.084). According to these results prior ICU stay, prior surgical procedure and renal disease were independent risk factors for the development of a CRKP infection/colonization.
Collapse
Affiliation(s)
| | - Antonis Valachis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Dimitra Dimopoulou
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Sofia Maraki
- Department of Clinical Bacteriology, University Hospital of Heraklion, Crete, Greece
| | - Athanasia Christidou
- Department of Clinical Bacteriology, University Hospital of Heraklion, Crete, Greece
| | - Elpis Mantadakis
- Department of Pediatrics, Democritus University of Thrace, Alexandroupolis, Thrace, Greece
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| |
Collapse
|
44
|
Viale P, Giannella M, Lewis R, Trecarichi EM, Petrosillo N, Tumbarello M. Predictors of mortality in multidrug-resistantKlebsiella pneumoniaebloodstream infections. Expert Rev Anti Infect Ther 2014; 11:1053-63. [DOI: 10.1586/14787210.2013.836057] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
45
|
Risk factors for the first episode of Klebsiella pneumoniae resistant to carbapenems infection in critically ill patients: a prospective study. BIOMED RESEARCH INTERNATIONAL 2013; 2013:850547. [PMID: 24455733 PMCID: PMC3878391 DOI: 10.1155/2013/850547] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/12/2013] [Accepted: 10/02/2013] [Indexed: 11/17/2022]
Abstract
Objective. To identify risk factors for the first episode of Klebsiella Pneumonia resistant to carbapenems (KPRC) infection in critically ill patients. Design, Setting, and Methods. This prospective cohort study was conducted in a 12-bed general Intensive Care Unit (ICU) in a University Hospital on ICU patients who required mechanical ventilation (MV) for >48 hours during a 12-month period. Clinical and microbiologic data were studied. Characteristics of KPRC patients were compared with those of critically ill patients who presented nonmultidrug resistant (MDR) bacterial infections or no documented infection at all. Results. Twenty-five patients presented KPRC infection, 18 presented non-MDR bacterial infection, and 39 patients presented no infection. Compared to patients without documented infection or infected by non MDR bacteria, patients with KPRC infection had received more frequently or for longer duration antibiotics against Gram-negative bacteria (carbapenems, colistin P < 0.05). Duration of colistin administration prior to KPRC isolation was independently associated with increased frequency of KPRC infection (odds ratio, 1.156 per day; 95% confidence interval, 1.010 to 1.312; P = 0.025). KPRC patients stayed longer in the ICU and received mechanical ventilation and sedation for longer periods and presented increased mortality (P < 0.05). Conclusion. KPRC infection is an emerging problem which might be more common in patients with previous use of antibiotics and especially colistin.
Collapse
|
46
|
Saidel-Odes L, Borer A. Limiting and controlling carbapenem-resistant Klebsiella pneumoniae. Infect Drug Resist 2013; 7:9-14. [PMID: 24353433 PMCID: PMC3862651 DOI: 10.2147/idr.s44358] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) is resistant to almost all antimicrobial agents, is associated with substantial morbidity and mortality, and poses a serious threat to public health. The ongoing worldwide spread of this pathogen emphasizes the need for immediate intervention. This article reviews the global spread and risk factors for CRKP colonization/infection, and provides an overview of the strategy to combat CRKP dissemination.
Collapse
Affiliation(s)
- Lisa Saidel-Odes
- Infection Control and Hospital Epidemiology Unit, Ben-Gurion University of the Negev, Beer-Sheva, Israel ; Infectious Diseases Institute, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Abraham Borer
- Infection Control and Hospital Epidemiology Unit, Ben-Gurion University of the Negev, Beer-Sheva, Israel ; Infectious Diseases Institute, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
47
|
Lee GC, Lawson KA, Burgess DS. Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae in Community Hospitals. Ann Pharmacother 2013; 47:1115-21. [DOI: 10.1177/1060028013503120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The occurrence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing at an alarming rate worldwide. Despite that increase, there are limited data identifying risk factors. Objective: To evaluate risk factors associated with the acquisition of CRE among hospitalized patients. Methods: We performed a retrospective case-case-control study in 4 community hospitals from June 2007 through June 2012. Case group 1 (CG1) consisted of patients with CRE. Case group 2 (CG2) consisted of patients with carbapenem susceptible Enterobacteriaceae (CSE). CG2 patients were matched to CG1 patients by site of infection and species of Enterobacteriaceae. Hospitalized controls were matched 2:1 by date of admission and hospital location to patients in CG1. Two sets of analyses were conducted comparing demographics, comorbidities, and antibiotic exposures of CG1 and CG2 to controls and then contrasted to identify unique risk factors associated with CRE. Results: Overall, 104 patients (CG1, 25 patients; CG2, 29 patients, control, 50 patients) were evaluated. CRE and CSE consisted mostly of Klebsiella spp. (63%) from a urinary source (28%). In multivariable analyses, intensive care unit (ICU) stay (OR 12.48; 95% CI 1.14-136.62; p = 0.04) and cumulative number of antibiotic days (OR 1.47; 95% CI 1.02-2.16; p = 0.04) were distinct independent predictors of CRE isolation; whereas, cumulative health care exposures (OR 2.03; 95% CI 1.20-3.41; p < 0.01) and vancomycin exposure (OR 6.70; 95% CI 1.15- 38.91; p = 0.03) were predictors for CSE. Conclusions: CRE should be considered in patients requiring ICU admission, particularly those who have received multiple antibiotics. Antibiotic stewardship efforts should be directed at reducing all antibiotic exposures as opposed to any specific antibiotic class to reduce the risk of CRE.
Collapse
Affiliation(s)
- Grace C. Lee
- University of Texas Health Science Center, San Antonio, TX, USA
- University of Texas at Austin, TX, USA
| | | | | |
Collapse
|
48
|
Petrosillo N, Giannella M, Lewis R, Viale P. Treatment of carbapenem-resistant Klebsiella pneumoniae: the state of the art. Expert Rev Anti Infect Ther 2013; 11:159-77. [PMID: 23409822 DOI: 10.1586/eri.12.162] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The increasing incidence of carbapenem-resistant Klebsiella pneumoniae (CR-KP) fundamentally alters the management of patients at risk to be colonized or infected by such microorganisms. Owing to the limitation in efficacy and potential for toxicity of the alternative agents, many experts recommend using combination therapy instead of monotherapy in CR-KP-infected patients. However, in the absence of well-designed comparative studies, the best combination for each infection type, the continued role for carbapenems in combination therapy and when combination therapy should be started remain open questions. Herein, the authors revise current microbiological and clinical evidences supporting combination therapy for CR-KP infections to address some of these issues.
Collapse
Affiliation(s)
- Nicola Petrosillo
- 2nd Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | | | | | | |
Collapse
|
49
|
Carbapenem Resistance and Mortality in Institutionalized Elderly With Urinary Infection. J Am Med Dir Assoc 2013; 14:513-7. [DOI: 10.1016/j.jamda.2013.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/21/2013] [Accepted: 02/22/2013] [Indexed: 11/23/2022]
|
50
|
Schechner V, Kotlovsky T, Kazma M, Mishali H, Schwartz D, Navon-Venezia S, Schwaber M, Carmeli Y. Asymptomatic rectal carriage of blaKPC producing carbapenem-resistant Enterobacteriaceae: who is prone to become clinically infected? Clin Microbiol Infect 2013; 19:451-6. [DOI: 10.1111/j.1469-0691.2012.03888.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|