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Weber A, Neffe L, Diaz LAP, Thoma N, Aghdassi SJS, Denkel LA, Maechler F, Behnke M, Häussler S, Gastmeier P, Kola A. Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing. J Hosp Infect 2023; 140:96-101. [PMID: 37562589 DOI: 10.1016/j.jhin.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. AIM To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. METHODS An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. FINDINGS A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. CONCLUSION For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.
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Affiliation(s)
- A Weber
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - L Neffe
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany
| | - L A P Diaz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - N Thoma
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S J S Aghdassi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Programme, Berlin, Germany
| | - L A Denkel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - F Maechler
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - M Behnke
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S Häussler
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany; TWINCORE, Centre for Experimental and Clinical Infection Research, A Joint Venture of the HZI and the Hannover Medical School, Hannover, Germany
| | - P Gastmeier
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - A Kola
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.
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Larrosa MN, Almirante B. Isolation strategy for controlling the spread of multidrug-resistant organisms: Is this still an essential option in hospitals? ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2021; 39:425-428. [PMID: 34736746 PMCID: PMC8560164 DOI: 10.1016/j.eimce.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/24/2022]
Affiliation(s)
- María Nieves Larrosa
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Spanish Network of Investigation in Infectious Diseases (RD16/0016/0003), Spain.
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Spanish Network of Investigation in Infectious Diseases (RD16/0016/0003), Spain
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Larrosa MN, Almirante B. Isolation strategy for controlling the spread of multidrug-resistant organisms: Is this still an essential option in hospitals? Enferm Infecc Microbiol Clin 2021; 39:S0213-005X(21)00188-9. [PMID: 34154857 PMCID: PMC8213526 DOI: 10.1016/j.eimc.2021.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/02/2022]
Affiliation(s)
- María Nieves Larrosa
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Spanish Network of Investigation in Infectious Diseases (RD16/0016/0003), Spain.
| | - Benito Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Spanish Network of Investigation in Infectious Diseases (RD16/0016/0003), Spain
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Vink J, Edgeworth J, Bailey SL. Acquisition of MDR-GNB in hospital settings: a systematic review and meta-analysis focusing on ESBL-E. J Hosp Infect 2020; 106:419-428. [PMID: 32918969 DOI: 10.1016/j.jhin.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/03/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) and other multi-drug-resistant Gram-negative bacteria (MDR-GNB) have disseminated globally since their discovery in the late 20th century. Various infection prevention and control measures are in place to prevent nosocomial transmission of these organisms, but their efficacy remains disputed. New literature has emerged in recent years providing further evidence which can be used to formulate effective strategies to tackle this issue in the future. METHODS A systematic review was performed to characterize the prevalence of colonization of multi-drug-resistant organisms and subsequent acquisition of these organisms within hospital settings. A meta-analysis was performed to characterize the prevalence and acquisition of ESBL-E in Europe and North America. RESULTS Twenty-eight studies fulfilled the inclusion criteria. Escherichia coli formed the main burden of MDR-GNB colonization worldwide. Patient-to-patient transmission of ESBL-E was found to be rare, but increased transmissibility of Klebsiella pneumoniae was described over E. coli. Within European and North American healthcare settings, a meta-analysis of eight studies identified a pooled prevalence of ESBL-E on admission to hospital of 7.91% and an acquisition rate of 3.73%. DISCUSSION Low prevalence at the point of hospital admission and insufficient evidence of patient-to-patient transmission suggests that infection prevention and control measures such as universal surveillance screening and single-room isolation are unlikely to be practical or effective interventions in reducing the overall burden of ESBL-E in hospitals, in line with current European guidelines. Instead, it is argued that efforts should be placed on controlling the spread of these organisms and other MDR-GNB in the community, predominantly long-term care facilities.
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Affiliation(s)
- J Vink
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - J Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - S L Bailey
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK
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Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial. THE LANCET. INFECTIOUS DISEASES 2020; 20:575-584. [PMID: 32087113 DOI: 10.1016/s1473-3099(19)30626-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/02/2019] [Accepted: 10/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme. METHODS We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070. FINDINGS We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions. INTERPRETATION Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening. FUNDING European Commission.
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Prevel R, Boyer A, M’Zali F, Cockenpot T, Lasheras A, Dubois V, Gruson D. Extended spectrum beta-lactamase producing Enterobacterales faecal carriage in a medical intensive care unit: low rates of cross-transmission and infection. Antimicrob Resist Infect Control 2019; 8:112. [PMID: 31333839 PMCID: PMC6617905 DOI: 10.1186/s13756-019-0572-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Background Extended-spectrum beta-lactamases-producing Enterobacterales (ESBL-E) are disseminating worldwide especially in Intensive Care Units (ICUs) and are responsible for increased health costs and mortality. The aims of this work were to study ESBL-E dissemination in ICU and to assess the impact of ESBL-E fecal carriage on subsequent infections during a non-outbreak situation. Methods We therefore screened every patient at admission then once a week in a medical ICU between January and June 2015. Each ESBL-E isolate was characterized by ESBL genes PCR amplification and the clonal dissemination was assessed by Pulsed-Field Gel Electrophoresis (PFGE). Results Among the 608 screened patients, 55 (9%) were colonized by ESBL-E. Forty-four isolates were available for further analysis. Most of them (43/44, 98%) contained a ESBL gene from the CTX-M group. Only one case of ESBL-E cross-transmission occurred, even for acquired ESBL-E colonization. Subsequent infection by ESBL-E occurred in 6/55 (11%) patients and infecting ESBL-E strains were the colonizing ones. ESBL-E faecal carriage had a negative predictive value of 100% and a positive predictive value of 40% to predict ESBL-E ventilator associated-pneumonia (VAP). Alternatives to carbapenems consisting in piperacillin-tazobactam, ceftolozane-tazobactam and ceftazidime-avibactam were all active on this panel of ESBL-E. Conclusions ESBL-E expansion and acquisition in ICU in a non-outbreak situation are not any more fully explained by cross-transmission. Mechanisms underlying ESBL-E dissemination in ICU are still to investigate. Interestingly, as far as we know, our study demonstrates for the first time by PFGE that the colonizing strain is indeed the infecting one in case of subsequent ESBL-E infection. Nevertheless, subsequent ESBL-E infection remains a rare event conferring poor positive predictive value for ESBL-E colonization to predict ESBL-E VAP. Relevance of systematic ESBL-E faecal screening at ICU admission and during ICU stay needs further investigation.
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Affiliation(s)
- Renaud Prevel
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
| | - Fatima M’Zali
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | | | | | - Véronique Dubois
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
- Bacteriology laboratory, CHU Bordeaux, F-33000 Bordeaux, France
| | - Didier Gruson
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
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Prevel R, Boyer A, M'Zali F, Lasheras A, Zahar JR, Rogues AM, Gruson D. Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:170. [PMID: 31088542 PMCID: PMC6518813 DOI: 10.1186/s13054-019-2460-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU. METHODS Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy. RESULTS Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting. CONCLUSION Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
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Affiliation(s)
- Renaud Prevel
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France. .,UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France. .,, Bordeaux, France.
| | - Alexandre Boyer
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
| | - Fatima M'Zali
- UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France
| | - Agnès Lasheras
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France
| | - Jean-Ralph Zahar
- Unité INSERM - IAME UMR 1137, Université Paris-13, Bobigny, France
| | - Anne-Marie Rogues
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France.,Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000, Bordeaux, France
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
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