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Chen HY, Jean SS, Lee YL, Lu MC, Ko WC, Liu PY, Hsueh PR. Carbapenem-Resistant Enterobacterales in Long-Term Care Facilities: A Global and Narrative Review. Front Cell Infect Microbiol 2021; 11:601968. [PMID: 33968793 PMCID: PMC8102866 DOI: 10.3389/fcimb.2021.601968] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/06/2021] [Indexed: 01/15/2023] Open
Abstract
The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.
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Affiliation(s)
- Hsin-Yu Chen
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, Department of Emergency Medicine and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Lin Lee
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine and Center for Infection Control, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Yu Liu
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Po-Ren Hsueh
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Korula A, Perumalla S, Devasia AJ, Abubacker FN, Lakshmi KM, Abraham A, Mathews V, Srivastava A, Anandan S, Veeraraghavan B, George B. Drug‐resistant organisms are common in fecal surveillance cultures, predict bacteremia and correlate with poorer outcomes in patients undergoing allogeneic stem cell transplants. Transpl Infect Dis 2020; 22. [DOI: 10.1111/tid.13273] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/24/2020] [Indexed: 08/30/2023]
Affiliation(s)
- Anu Korula
- Department of Haematology Christian Medical College and Hospital Vellore India
| | | | - Anup J. Devasia
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Fouzia N. Abubacker
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Kavitha M. Lakshmi
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Aby Abraham
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Vikram Mathews
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Alok Srivastava
- Department of Haematology Christian Medical College and Hospital Vellore India
| | - Shalini Anandan
- Microbiology Christian Medical College and Hospital Vellore India
| | | | - Biju George
- Department of Haematology Christian Medical College and Hospital Vellore India
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Park CE. Clinical Laboratory Aspect of Carbapenem-Resistant Enterobacteriaceae. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2020. [DOI: 10.15324/kjcls.2020.52.1.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Chang-Eun Park
- Department of Biomedical Laboratory ScienceㆍMolecular Diagnostics Research Institute, Namseoul University, Cheonan, Korea
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Reducing the impact of carbapenem-resistant Enterobacteriaceae on vulnerable patient groups: what can be done? Curr Opin Infect Dis 2018; 29:555-560. [PMID: 27584588 DOI: 10.1097/qco.0000000000000313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Carbapenem-resistant Enterobacteriaceae (CRE) is a worldwide challenge and associated with a high mortality rate in critically ill patients. This review focused on rapid diagnosis, optimization of antimicrobial therapy, and implication of effective infection control precautions to reduce impact of CRE on vulnerable patients. RECENT FINDINGS Several new diagnostic assays have recently been described for the early diagnosis of CRE. Retrospective studies are supportive for colistin plus meropenem combination for the treatment of CRE infections; however, solid evidence is still lacking. Ceftazidime-avibactam may be an effective therapeutic agent for infections caused by carbapenem-hydrolyzing oxacillinase-48 and Klebsiella pneumoniae carbapenamase-producing Enterobacteriaceae, but not for New Delhi metallo-β-lactamase producers. Gastrointestinal screening may permit early identification of patients with CRE infections. There is not enough evidence to recommend selective digestive decontamination for CRE carriers. SUMMARY The information for rapid diagnosis of CRE is accumulating. There are new agents with high in-vitro activity against CRE, but clinical experience is limited to case reports. Active surveillance with a high rate of compliance to basic infection control precautions seems to be the best approach to reduce the impact of CRE on vulnerable patients.
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Aguirre-Quiñonero A, Martínez-Martínez L. Non-molecular detection of carbapenemases in Enterobacteriaceae clinical isolates. J Infect Chemother 2017; 23:1-11. [DOI: 10.1016/j.jiac.2016.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/28/2016] [Accepted: 09/28/2016] [Indexed: 01/11/2023]
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Aschbacher R, Pagani E, Confalonieri M, Farina C, Fazii P, Luzzaro F, Montanera PG, Piazza A, Pagani L. Review on colonization of residents and staff in Italian long-term care facilities by multidrug-resistant bacteria compared with other European countries. Antimicrob Resist Infect Control 2016; 5:33. [PMID: 27766146 PMCID: PMC5057254 DOI: 10.1186/s13756-016-0136-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/27/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Rates of colonization and infection with multidrug-resistant (MDR) bacteria are increasing worldwide, in both acute care hospitals and long-term care facilities (LTCFs). Italy has one of the highest prevalence of MDR bacteria in European countries, especially with regard to methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL) or carbapenemase producing Enterobacteriaceae (CPE). METHOD Review of studies on colonization by MDR bacteria from Italian LTCFs, risk factors for colonization and molecular characteristics of surveillance and clinical isolates, compared with other European countries. RESULTS High variability of MDR colonization has been reported within and especially between European countries. Only a few surveillance studies have been performed in Italian LTCFs; these show MRSA colonization prevalence of 7.8-38.7 % for residents and 5.2-7.0 % for staff members, ESBL prevalence of 49.0-64.0 % for residents and 5.2-14.5 % for staff and prevalence of CPE of 1.0-6.3 % for residents and 0.0-1.5 % for staff. In Italian LTCFs, as well as in other European countries, the most prevalent ESBLs from surveillance or clinical Escherichia coli isolates were found to be CTX-M-type enzymes, particularly CTX-M-15, expressed by the pandemic ST131 clonal group; this lineage also expresses carbapenemase genes of the blaVIM and blaKPC types. Various risk factors for colonization of residents by MDR bacteria were identified. CONCLUSIONS The limited data from Italian LTCFs confirms these settings as important reservoirs for MDR organisms, allowing important considerations regarding the infection risk by these organisms. Nevertheless, more extended and countrywide screening studies for MDR colonization in Italian LTCFs are required. To promote further studies of various microbiological aspects related to LTCFs, the Association of Italian Clinical Microbiologists (Associazione Microbiologi Clinici Italiani; AMCLI) in 2016 has set up a new Working Group for the Study of Infections in LTCFs (Gruppo di Lavoro per lo Studio delle Infezioni nelle Residenze Sanitarie Assistite e Strutture Territoriali assimilabili; GLISTer), consisting of Clinical Microbiologists represented by the authors of this review article.
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Affiliation(s)
- Richard Aschbacher
- Laboratorio Aziendale di Microbiologia e Virologia, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | - Elisabetta Pagani
- Laboratorio Aziendale di Microbiologia e Virologia, Comprensorio Sanitario di Bolzano, Bolzano, Italy
| | | | - Claudio Farina
- Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, USC Microbiologia e Virologia, Bergamo, Italy
| | - Paolo Fazii
- P.O. Spirito Santo Laboratorio Analisi, Pescara, Italy
| | - Francesco Luzzaro
- Ospedale A. Manzoni, Laboratorio Microbiologia e Virologia, Lecco, Italy
| | | | - Aurora Piazza
- Dipartimento SCCDP, Unità di Microbiologia e Microbiologia clinica, Pavia, Italy
| | - Laura Pagani
- Dipartimento SCCDP, Unità di Microbiologia e Microbiologia clinica, Pavia, Italy
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Prasad N, Labaze G, Kopacz J, Chwa S, Platis D, Pan CX, Russo D, LaBombardi VJ, Osorio G, Pollack S, Kreiswirth BN, Chen L, Urban C, Segal-Maurer S. Asymptomatic rectal colonization with carbapenem-resistant Enterobacteriaceae and Clostridium difficile among residents of a long-term care facility in New York City. Am J Infect Control 2016; 44:525-32. [PMID: 26796684 DOI: 10.1016/j.ajic.2015.11.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Residents of long-term care facilities (LTCFs) are at increased risk for colonization and development of infections with multidrug-resistant organisms. This study was undertaken to determine prevalence of asymptomatic rectal colonization with Clostridium difficile (and proportion of 027/NAP1/BI ribotype) or carbapenem-resistant Enterobacteriaceae (CRE) in an LTCF population. METHODS Active surveillance was performed for C difficile and CRE rectal colonization of 301 residents in a 320-bed (80-bed ventilator unit), hospital-affiliated LTCF with retrospective chart review for patient demographics and potential risk factors. RESULTS Over 40% of patients had airway ventilation and received enteral feeding. One-third of these patients had prior C difficile-associated infection (CDI). Asymptomatic rectal colonization with C difficile occurred in 58 patients (19.3%, one-half with NAP1+), CRE occurred in 57 patients (18.9%), and both occurred in 17 patients (5.7%). Recent CDI was significantly associated with increased risk of C difficile ± CRE colonization. Multivariate logistic regression analysis revealed presence of tracheostomy collar to be significant for C difficile colonization, mechanical ventilation to be significant for CRE colonization, and prior CDI to be significant for both C difficile and CRE colonization. CONCLUSIONS The strong association of C difficile or CRE colonization with disruption of normal flora by mechanical ventilation, enteral feeds, and prior CDI carries important implications for infection control intervention in this population.
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Affiliation(s)
- Nishant Prasad
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY; Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | - Georges Labaze
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Joanna Kopacz
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY; Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | - Sophie Chwa
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Dimitris Platis
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Cynthia X Pan
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; Division of Geriatrics and Palliative Medicine, NewYork-Presbyterian/Queens, Flushing, NY
| | - Daniel Russo
- Silvercrest Center for Nursing and Rehabilitation, Flushing, NY
| | | | - Giuliana Osorio
- Department of Pathology, NewYork-Presbyterian/Queens, Flushing, NY
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, St. John's University, Queens, NY
| | - Barry N Kreiswirth
- Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ
| | - Liang Chen
- Public Health Research Institute, New Jersey Medical School, Rutgers University, Newark, NJ
| | - Carl Urban
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY
| | - Sorana Segal-Maurer
- Department of Medicine, NewYork-Presbyterian/Queens, Flushing, NY; The Dr. James J. Rahal Jr. Division of Infectious Diseases, NewYork-Presbyterian/Queens, Flushing, NY.
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Clinical Performance of Check-Direct CPE, a Multiplex PCR for Direct Detection of bla(KPC), bla(NDM) and/or bla(VIM), and bla(OXA)-48 from Perirectal Swabs. J Clin Microbiol 2015; 53:3729-37. [PMID: 26338860 DOI: 10.1128/jcm.01921-15] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/23/2015] [Indexed: 12/13/2022] Open
Abstract
We evaluated the clinical performance of Check-Direct CPE for carbapenemase detection directly from 301 perirectal swabs (258 patients) in a nonoutbreak setting. Culture of a PCR-confirmed, carbapenemase-containing organism, or history of colonization with such organism within the previous 2 weeks, was used as the reference standard. Check-Direct CPE demonstrated a sensitivity value, specificity value, positive predictive value (PPV), and negative predictive value (NPV) of 100% (all bla(KPC)), 88%, 21%, and 100%, respectively. False positives accounted for 79% (n = 34) of samples for which a cycle threshold (C(T)) value was reached. Simulated studies to evaluate specimen pooling as an approach to minimize costs showed no difference in C(T) values for pooled groups of three or five that each contained a single specimen spiked with ∼1,500 CFU bla(KPC) Klebsiella pneumoniae; however, the detection rate dropped to 60% at a seeded concentration of ∼150 CFU. When data were pooled, C(T) values for bla(KPC) were higher for heavy-feces-containing than for light-feces-containing liquid-suspended specimens. Furthermore, C(T) values for liquid-suspended specimens were 4 to 5 C(T) values lower (i.e., represented greater sensitivity) than those seen in direct swab analysis. Culture was equivalent to or better than Check-Direct CPE for 13/15 (87%) isolates tested in a limit-of-detection analysis. Detection of a carbapenemase gene at a C(T) cutoff value of ≤35 was culture confirmed in 23/24 (96%) of cases; however, C(T) values of >35 overlapped broadly between culture-positive (n = 21) and culture-negative (n = 36) specimens. Check-Direct CPE will likely prove most useful in high-prevalence areas or in outbreak settings where rapid carbapenemase detection is critical for infection control management.
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