Infection-prevention and control interventions to reduce colonisation and infection of intensive care unit-acquired carbapenem-resistant Klebsiella pneumoniae: a 4-year quasi-experimental before-and-after study

A comprehensive evaluation of risk factors for mortality, infection and colonization associated with CRGNB in adult solid organ transplant recipients: a systematic review and meta-analysis

BACKGROUND

The burden of carbapenem-resistant gram-negative bacteria (CRGNB) among solid organ transplant (SOT) recipients has not been systematically explored. Here, we discern the risk factors associated with CRGNB infection and colonization in SOT recipients.

METHODS

This study included observational studies conducted among CRGNB-infected SOT patients, which reported risk factors associated with mortality, infection or colonization. Relevant records will be searched in PubMed, Embase and Web of Science for the period from the time of database construction to 1 March 2023.

RESULTS

A total of 23 studies with 13,511 participants were included, enabling the assessment of 27 potential risk factors. The pooled prevalence of 1-year mortality among SOT recipients with CRGNB was 44.5%. Prolonged mechanical ventilation, combined transplantation, reoperation and pre-transplantation CRGNB colonization are salient contributors to the occurrence of CRGNB infections in SOT recipients. Renal replacement therapy, post-LT CRGNB colonization, pre-LT liver disease and model for end-stage liver disease score increased the risk of infection. Re-transplantation, carbapenem use before transplantation and ureteral stent utilization increaesd risk of CRGNB colonization.

CONCLUSION

Our study demonstrated that SOT recipients with CRGNB infections had a higher mortality risk. Invasive procedure may be the main factor contribute to CRGNB infection.

The ICU-CARB score: a novel clinical scoring system to predict carbapenem-resistant gram-negative bacteria carriage in critically ill patients upon ICU admission

BACKGROUND

With the widespread spread of carbapenem-resistant gram-negative bacteria (CR-GNB) in medical facilities, the carriage of CR-GNB among critically ill patients has become a significant concern in intensive care units (ICU). This study aimed to develop a scoring system to identify CR-GNB carriers upon ICU admission.

METHODS

Consecutive critically ill patients admitted to the ICU of Shanghai Ruijin Hospital between January 2017 and December 2020 were included. The patients were then divided into training and testing datasets at a 7:3 ratio. Parameters associated with CR-GNB carriage were identified using least absolute shrinkage and selection operator regression analysis. Each parameter was assigned a numerical score ranging from 0 to 100 using logistic regression analysis. Subsequently, a four-tier risk-level system was developed based on the cumulative scores, and assessed using the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 1736 patients included in this study, the prevalence of CR-GNB carriage was 10.60%. The clinical scoring system including seven variables (neurological disease, high-risk department history, length of stay ≥ 14 days, ICU history, invasive mechanical ventilation, gastrointestinal tube placement, and carbapenem usage) exhibited promising predictive capabilities. Patients were then stratified using the scoring system, resulting in CR-GNB carriage rates of 2.4%, 12.0%, 36.1%, and 57.9% at the respective risk levels (P < 0.001). Furthermore, the AUC of the developed model in the training set was calculated to be 0.82 (95% CI, 0.78-0.86), while internal validation yielded an AUC of 0.83 (95% CI, 0.77-0.89).

CONCLUSIONS

The ICU-CARB Score serves as a straightforward and precise tool that enables prompt evaluation of the risk of CR-GNB carriage at the time of ICU admission, thereby facilitating the timely implementation of targeted pre-emptive isolation.

Antibiotic Resistance Pattern in Intensive Care Units in a Large Referral Hospital in Iran

Background & Objective

Antibiotic resistance, especially in the form of multidrug-resistant (MDR), is a big problem, especially in intensive care units (ICUs). This study aimed to evaluate antibiotic resistance and MDR patterns among patients hospitalized in the ICUs in one of the large referral centers in Iran.

Methods

The present study was conducted at Imam Khomeini Hospital in Tehran (a great referral hospital), which admits critically ill patients requiring ICU services. To determine the rate of positive cultures for resistant strains, the patient's blood specimens were sent to the laboratory of the hospital for inoculation on proper culture media within 2 hours of extraction. Antimicrobial susceptibility tests were done using the Bauer-Kirby disk diffusion method.

Results

A total of 1,755 samples were collected from the patients to assess microbial strains and antibiotic resistance. The most common microbial strains detected in the cultures extracted from peripheral blood samples were Klebsiella pneumonia (22.1%), Staphylococcus epidermidis (7.9%) and another coagulase-negative Staphylococcus (15.0%). The antibiogram test showed antibiotic resistance in 1,509 cases, leading to a resistance prevalence rate of 85.9%. The most common antimicrobial resistance observed was against cotrimoxazole (61.7%), ciprofloxacin (51.3%), imipenem (50.0%), and ampicillin (49.6%). The rate of MDR was found to be 96.3%.

Conclusion

In Iran's ICUs, a significantly high level of antibiotic resistance may be seen especially the MDR pattern, which indicates the need to change the pattern of prescribing and managing these drugs in ICU centers.

Efficacy of Active Rapid Molecular Screening and IPC Interventions on Carbapenem-Resistant Enterobacterales Infections in Emergency Intensive Care Units without Enough Single-Room Isolation

Purpose

To investigate whether rapid active molecular screening and infection prevention and control (IPC) interventions can reduce colonization or infection with carbapenem-resistant Enterobacterales (CRE) in a general emergency intensive care unit (EICU) without enough single-room isolation.

Methods

The study was designed as a before-and-after quasi-experiment. Before the experimental period, the ward was rescheduled and the staff were trained. From May 2018 to April 2021, active screening was performed by seminested real-time fluorescent polymerase chain reaction (PCR) detection with rectal swabs from all patients on admission to the EICU, and the results were reported in 1 hour. Other IPC interventions including hand hygiene, contact precautions, patient isolation, environmental disinfection, environment surveillance, monitoring, auditing and feedback were conducted under strict supervision. The patients' clinical characteristics were collected simultaneously.

Results

In this 3-year study, 630 patients were enrolled and 19.84% of the patients were initially colonized or infected with CRE as shown by active molecular screening. The average drug resistance ratio to carbapenem shown by clinical culture detection of Klebsiella pneumoniae (KPN) before the study was performed was 71.43% in EICU. The drug resistance ratio decreased significantly from 75%, 66.67% to 46.67% in the next 3 years (p<0.05) during which active screening and IPC interventions were strictly executed. While the ratio gaps between EICU and the whole hospital were narrowed from 22.81%, 21.11% to 4.64%. Patients with invasive devices, skin barrier damage, and the recent use of antibiotics on admission were found to have a higher risk of being colonized or infected with CRE (p<0.05).

Conclusion

Active rapid molecular screening and other IPC interventions may significantly reduce CRE nosocomial infections even in wards without enough single-room isolation. The key to reduce the spread of CRE in the EICU is the strict execution of IPC interventions by all medical staff and healthcare workers.

Drug Resistance Genes and Molecular Epidemiological Characteristics of Carbapenem-Resistant Klebsiella pneumonia

Background

The global prevalence of carbapenem-resistant Klebsiella pneumoniae (CRKP) has become a serious challenge for nosocomial infection and attracted worldwide attention. This study explored the drug resistance genes and molecular characteristics for CRKP, providing a reference for nosocomial prevention and control.

Methods

A total of 42 CRKP isolates were collected from the First Affiliated Hospital of Gannan Medical University (Ganzhou, China) from January 2018 to February 2021. The drug resistance of CRKP was tested by the VitekII Compact system. Drug resistance gene expression was detected by poly-merase chain reaction (PCR), and molecular typing was performed by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST).

Results

All the 42 CRKP isolates were multi-drug resistant. Among them, 35 isolates (83.3%) produced bla_KPC-2 and 12 isolates (28.6%) produced bla_NDM-1. The detection rate of bla_IMP-4 and bla_OXA-48 was 2.4% (1/42), respectively. Twelve isolates (28.6%) carried both bla_KPC-2 and bla_NDM-1, one isolate (2.4%) carried both bla_KPC-2 and bla_IMP-4, and one isolate (2.4%) carried bla_KPC-2, bla_NDM-1 and bla_OXA-48. A variety of other extended-spectrum beta-lactamases (ESBLs) were also detected. All 42 isolates carried bla_SHV and bla_CTX-M-1, 27 isolates (64.3%) carried bla_TEM and 12 isolates (28.6%) carried bla_CTX-M-9. The MLST data classified the 42 CRKP isolates into 11 sequence types, mainly ST11, accounting for 61.9% (26/42), of which 92.3% of isolates (24/26) carrying bla_KPC-2. The PFGE results demonstrated that the 42 CRKP isolates could be divided into 20 clusters A-T, with cluster A (26.2%, 11/42) and cluster H (21.4%, 9/42) dominating, which were all ST11.

Conclusion

The CRKP isolates were severely multi-drug resistant, and the main resistant gene was bla_KPC-2 production, carrying multiple ESBLs genes simultaneously. The MLST and PFGE revealed that the ST11-bla_KPC-2 Klebsiella pneumoniae was the main clonotype. Our findings may offer help to antibiotics selection and nosocomial infection prevention and control.

Effects of screening strategies to detect carbapenem-resistant gram-negative bacteria: A systematic review

OBJECTIVE

This systematic review aims to summarize the evidence on the effects of screening strategies to detect carbapenem-resistant gram-negative bacteria (Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa).

METHODS

Eligible studies were randomized trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. We conducted searches in CENTRAL, PUBMED, Embase, Epistemonikos, and in multiple databases available in the Virtual Health Library (LILACS, Scielo, WHO IBECS, and PAHO IBECS). All the searches covered the period until 4 June 2021. No date or language restrictions were applied. Two reviewers independently evaluated potentially eligible studies according to predefined selection criteria, and extracted data on study characteristics, methods, outcomes, and risk of bias, using a predesigned standardized form. When possible, we intended to conduct meta-analyses using a random-effect model. We assessed the certainty of the evidence (CoE) and summarized the results using the GRADE approach.

RESULTS

Our search strategy yielded 57,451 references. No randomized trials were identified. Sixteen studies (one controlled before-after study and 15 interrupted time series) met our inclusion criteria and were included in the review. Most studies were conducted in tertiary care general hospitals from the United States, Europe, and Asia. Eleven studies included adult patients hospitalized in general wards and intensive care units, one was carried out in a neonatal intensive care unit, two in hematology or oncology units, and one in a solid organ transplantation department. Eleven studies were conducted in the setting of an outbreak. Regarding the detection strategy used, all studies included screening strategies for high-risk patients at the moment of admission and 7 studies reported a contact surveillance strategy. Most studies were conducted in settings where infection prevention and control measures were concomitantly installed or reinforced. Data were not suitable for meta-analysis, so the results were presented as a narrative synthesis. Most studies showed a decline in the prevalence of both infection and colonization rates after the implementation of a policy of active surveillance, but the CoE is low. Screening strategies may result in little to no difference in the risk of all-cause mortality and the length of hospital stay.

CONCLUSIONS

Existing evidence may favor the use of surveillance culture to carbapenem-resistant gram-negative bacteria, but its quality is poor, so solid conclusions cannot be drawn. Well-conducted randomized trials or high-quality quasi-experimental studies are needed to improve the certainty of the existing evidence. These studies should assess the effect of the addition of screening strategies as a single intervention and measure clinically important outcomes such as infection, length of hospital stay, and mortality.

Infection prevention and control strategies against carbapenem resistant Enterobacteriaceae - a systematic review

Background

Antimicrobial resistance is exponentially worsening, and the spread of prevalent carbapenem resistant Enterobacteriaceae (CRE) is a major contributor to this global concern. Infection prevention and control strategies are increasingly consolidated key tools to control this worldwide problem.

Aim

To identify, collect and analyse available evidence regarding the impact of infection prevention and control strategies on prevalent CRE dissemination.

Methods

Pubmed®, Scopus® and Web of Science® were searched systematically for articles published between 1th January 2017 and 30th June 2020, guided by the research question 'What are the most effective and efficient strategies to prevent and control infection/colonisation caused by Carbapenem resistant Escherichia coli and Carbapenem resistant Klebsiella pneumoniae?'.

Findings

Eleven thousand six hundred and thirty-five publications were found, but after applying the inclusion and exclusion criteria, only 30 were selected. The majority of reviewed studies (n = 24) were performed in outbreak situations, 26 studies occurred in acute care units and of those, 17 in intensive care units . From the set of implemented infection prevention and control measures, in 29 studies surveillance cultures were applied, in 23 studies patients were isolated or cohorted and, in general, all described the implementation of standard and contact precaution measures.

Conclusion

This systematic review underlines the importance of infection prevention and control strategies in CRE dissemination, standing out the need of further studies outside outbreak and intensive care units contexts. Investment increments and training and educating of all involved are also important contributors to shift this problem, but still with relevant gaps in their implementation, in all types of care units, that need to be addressed.

Failure mode and effects analysis on the control effect of multi-drug-resistant bacteria in ICU patients

OBJECTIVE

The failure mode and effect analysis of the prevention and control in intensive care unit (ICU) patients with multi-drug-resistant (MDR) bacterial infection were explored and analyzed in this research.

METHODS

A total of 251 critically ill patients who were hospitalized in the ICU from June to December 2019 were selected as the control group, and another 258 patients who were hospitalized in the ICU from January to June 2020 were set as the observation group. The control-group patients received conventional ICU care, the observation group was treated by the failure mode and effects analysis (FMEA), and then the prevention and control effect of the two nursing modes on multi-drug-resistant bacteria infection in the two groups were compared accordingly.

RESULTS

The RPN values of the five highest-level factors in the nursing process were critically lower after the improved interventions than before the improvement. The infection rate of MDR bacteria in the observation group was obviously lower than that in the control group (14.73%, 26.69%, χ² =11.1233, P=0.0009). In addition, the mortality rate of patients with MDR in the observation group was remarkably lower than that in the control group, and the difference was statistically significant (5.26%, 22.39%, χ² =5.2405, P=0.0221). The satisfaction of the observation group with the ICU treatment was critically higher than that of the control group, and the difference was statistically significant (89.53%, 76.49%, χ² =15.4094, P=0.0001).

CONCLUSION

Through the application of FMEA to prevent MDR bacterial infection in ICU patients, nursing staff can accurately pay attention to the keynotes in nursing process, and as such reduce the proportion and mortality of MDR infection in ICU patients and promote the patients' satisfaction with nursing, which are all worthy of clinical application.

Carbapenem-Resistant Klebsiella pneumoniae in Southwest China: Molecular Characteristics and Risk Factors Caused by KPC and NDM Producers

Background

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has attracted worldwide concern and became a serious challenge for clinical treatment. The aims of this study were to evaluate the molecular characteristics and risk factors for CRKP infection.

Methods

All the CRKP strains were screened for antimicrobial resistance genes, virulence genes, and integron by polymerase chain reaction (PCR). Plasmid typing was performed by plasmid conjugation assay and PCR-based replicon typing (PBRT). The genetic environments of bla_KPC-2 and bla_NDM-1 were analyzed by using overlapping PCR and molecular typing was performed by multi-locus sequence typing (MLST). Risk factors for CRKP infection were analyzed by logistic regression model.

Results

All the 66 CRKP isolates were multidrug-resistant, but all of them were susceptible to tigecycline and polymyxin B. Among the CRKP isolates, 42 bla_KPC-2-positive strains were identified carrying IncFII plasmids. Meanwhile, 24 bla_NDM-positive strains were found on lncX3 plasmids, including 20 bla_NDM-1 isolates and 4 bla_NDM-5 isolates. Most of CRKP isolates contained several virulence genes and the class I integron (intl1). The genetic environments of bla_KPC-2 and bla_NDM-1 revealed that the conserved regions (tnpA-tnpR-ISkpn8-bla_KPC-2) and (bla_NDM-1-ble_MBL-trpF-tat) were associated with the dissemination of KPC-2 and NDM-1. ST11 was the most common type in this work. Hematological disease, tracheal cannula, and use of β-lactams and β-lactamase inhibitor combination were identified as independent risk factors for CRKP infection.

Conclusion

This study established the resistance pattern, molecular characteristics, clonal relatedness, and risk factors of CRKP infection. The findings of the novel strain that co-harboring bla_NDM-5 and bla_IMP-4, and the novel ST4495 indicated that the brand-new types have spread in Southwest China, emphasizing the prevent and control the further dissemination of CRKP isolates are highly needed.

Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: a scoping review

OBJECTIVES

This study assessed antimicrobial stewardship (AMS) and infection prevention (IP) interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections, their key outcomes and the application of behaviour change principles in these interventions.

DESIGN

This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines while focusing on acute healthcare settings in both low-to-middle income and high-income countries.

DATA SOURCES

The databases searched were MEDLINE, PubMed, Web of Science and CINAHL between 22 April 2020 and 30 September 2020.

ELIGIBILITY

The review included peer-reviewed articles published in English language between 2010 and 2019. Studies that focussed on IP and/or AMS interventions primarily targeting C. difficile or CRKP were included. Studies that assessed effectiveness of diagnostic devices or treatment options were excluded from this review.

DATA EXTRACTION AND SYNTHESIS

An abstraction sheet calibrated for this study was used to extract data on the main study characteristics including the population, intervention and outcomes of interest (antimicrobial use, compliance with IP interventions and risk for C. difficile and CRKP). A narrative synthesis of the results is provided.

RESULTS

The review included 34 studies. Analysis indicates that interventions targeting C. difficile and CRKP include Education, Surveillance/Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles, Isolation as well as Notifications or alerts (represented using the ESCAPE-BIN acronym). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay and time savings. AMS and IP interventions tend to be more adhoc with limited application of behaviour change principles.

CONCLUSION

This scoping review identified the AMS and IP interventions targeting C. difficile and CRKP in healthcare settings and described their key outcomes. The application of behaviour change principles in AMS and IP interventions appears to be limited.

Validation and Extrapolation of a Multimodal Infection Prevention and Control Intervention on Carbapenem-Resistant Klebsiella pneumoniae in an Epidemic Region: A Historical Control Quasi-Experimental Study

Objective: To verify the effects of comprehensive infection prevention and control (IPC) interventions for the prevention of the cross-transmission of carbapenem-resistant Klebsiella pneumoniae (CRKP) within intensive care units (ICUs) in an epidemic region.

Methods: A historical control, quasi-experimental design was performed. The study was conducted between January 2017 and December 2019, following the implementation of a multimodal IPC bundle. The baseline period was established from January 2013 to June 2013, when only basic IPC measures were applied.

Results: A total of 748 patients were enrolled during the entire study. The incidence of ICU-acquired CRKP colonization/infection was 1.16 per 1,000 patient-days during the intervention period, compared with 10.19 per 1,000 patient-days during the baseline period (p = 0.002). The slope of the monthly incidence of CRKP at admission showed an increasing trend (p = 0.03). The incidence of ICU-acquired catheter-related bloodstream infections caused by CRKP decreased from 2.54 to 0.96 per 1,000 central-line-days (p = 0.08). Compliance with contact precautions and terminal room disinfection improved during the intervention period. All environmental surface culture samples acquired after terminal room disinfection were negative for CRKP.

Conclusion: Our findings suggest that in epidemic settings, multimodal IPC intervention strategies and consistent monitoring of compliance, may limit the spread of CRKP in ICUs.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Impact of multicenter unified enhanced environmental cleaning and disinfection measures on nosocomial infections among patients in intensive care units

Objectives

Most Chinese hospitals have customized environmental cleaning policies and systems, with limited data availability based on evidence-based medicine. This study investigated the relationship between multidrug-resistant organism (MDRO) colonization in intensive care unit (ICU) patients and ICU surface bacterial contamination status.

Methods

This cross-sectional study comprised MDRO screening in ICU patients using bacterial cultivation by chromogenic medium; samples were collected before (control group) and after implementation of enhanced cleaning (cleaning group). Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry was used to identify and analyze microorganisms; the relationships of MDRO colonization with infection and environmental bacteria were analyzed.

Results

In total, 196 patients were enrolled in the study (104 and 92 in control and cleaning groups, respectively); 1042 MDROs were subjected to screening before and after cleaning. After cleaning, the rate of MDRO detection on surfaces of frequently touched objects in ICUs decreased from 31.77% to 13.32%. There were fewer MDRO homologues in the cleaning group than in the control group. Moreover, the cleaning group had a shorter ICU stay and significantly lower mortality rate.

Conclusions

Enhanced environmental cleaning and disinfection could reduce environmental MDRO accumulation and suppress MDRO colonization in ICUs, thereby reducing nosocomial infections and improving adverse patient outcomes.

Phenotypic Detection of Carbapenem-Resistant Gram-Negative Bacilli from a Clinical Specimen in Sidama, Ethiopia: A Cross-Sectional Study

BACKGROUND

Carbapenem-resistant gram-negative bacteria are an emergent source of both community-acquired and healthcare-associated infection that poses a substantial hazard to public health. This study aimed to conclude the magnitude of carbapenem resistance gram-negative bacteria from a clinical specimen at Hawassa University Comprehensive Specialized Hospital.

METHODS

A hospital-based cross-sectional study was accompanied from February 13 to June 7, 2020, in which consecutive patients with 103 gram-negative bacteria were encompassed. The isolates included were 54 urine, 17 blood, 17 pusses, 4 cerebrospinal fluid (CSF), 3 aspirates, 3 effusions, 2 stools, 2 ear discharges, and 1 nasal swab. A semi-structured questionnaire was used to gather socio-demographic data from the attendant and clinical data from the patient's chart. Patients admitted in any wards and visited outpatients department were included for the study if gram-negative bacteria was identified for those who accepted the consent. A routine manual culture, Gram's staining and biochemical tests used to identify the bacteria. Antibiotic susceptibility was determined for twelve antibiotics including cotrimoxazole, ceftazidime, meropenem, gentamycin, chloramphenicol, ampicillin, ciprofloxacin, cefotaxime, cefuroxime, nitrofurantoin, piperacillin-tazobactam, and amikacin using the Kirby-Bauer disc diffusion method. Modified carbapenem inactivation (mCIM) method was used to determine carbapenem resistance using meropenem disk as per the recommendation of Clinical and Laboratory Standards Institute guideline. Statistical package for social science software version 21 was used for data entry and analysis. The odds ratio at 95% confidence interval (CI) and p-value <0.05 were taken as a statistically significant association.

RESULTS

Generally, 111 gram-negative bacteria were identified from 103 patients. Of 111 isolates, thirteen isolates (nine resistance and four intermediates) were identified in disk diffusion testing for meropenem. Of this, 10 isolates were carbapenemases producer with the overall rates of 9% in the Modified carbapenem inactivation method (mCIM). Pseudomonas spp. 3 (30.0%), E. coli, K. pneumonia, Acinetobacter spp. each two (20.0%), and K. oxytoca 1 (10.0%) were identified as carbapenemases positive. The rates of the multidrug, extensive, pan drug were 86.5, 43.3, and 1.8, respectively. Ampicillin 94 (97.9%), followed by cefuroxime 52 (91.2%), cefotaxime 94 (88.7%), cotrimoxazole 58 (88.1%), ceftazidime 40 (83.3%), ciprofloxacin 47 (77.1%), nitrofurantoin 35 (70.0%), gentamycin 71 (65.7%), with high level of resistance. However, piperacillin-tazobactam 41 (48.8%), chloramphenicol 25 (47.2%), meropenem 13 (11.7%), and amikacin 9 (8.5%) were with low rates of resistance. In this study, there were no variables statically associated with carbapenem resistance that is p > 0.05.

CONCLUSION

Our study showed that carbapenem-resistant gram-negative bacilli are 9% in the study area. Our finding signposts that ampicillin, cefuroxime, cefotaxime, cotrimoxazole, ceftazidime, ciprofloxacin, nitrofurantoin, and gentamycin with a high rate of resistance >50%. However, piperacillin-tazobactam, chloramphenicol, meropenem, and amikacin were at low rates of resistance. Therefore, a measure should be taken to contain carbapenem resistance gram-negative bacteria in the study area. Further, study with better method needs to be conducted to conclude the real scenario of carbapenem resistance.

Epidemiology, mortality and risk factors for patients with K. pneumoniae bloodstream infections: Clinical impact of carbapenem resistance in a tertiary university teaching hospital of Beijing

BACKGROUND

This study compared the epidemiology of carbapenem-resistant (CRKP) and carbapenem-sensitive (CSKP) K. pneumoniae bloodstream infections (BSIs), and assessed risk factors for 28-day mortality of patients with K. pneumoniae BSIs.

METHODS

A retrospective cohort study was conducted in a 2000-bed tertiary teaching hospital of Beijing between Jan 1st 2013 to Dec 31st, 2019. All patients with K. pneumoniae BSI were identified through the Hospital Information System. The endpoints included incidence rate, mortality and risk factors for mortality of patients with K. pneumoniae BSIs.

RESULTS

496 patients with K. pneumoniae BSIs were included in the analysis, with 108 CRKP BSIs. The incidence rate of K. pneumoniae BSI was 10.6 (CI: 9.7, 11.6) per 100 000 patient-days, with the rate for CRKP BSI was 2.3 (95% CI: 1.9, 2.8). The 28-day mortality was 38.0% for CRKP BSI and 8.8% for CSKP BSI, respectively. Logistic analysis showed, higher Charlson Comorbidity Index score (OR = 1.26, 95%CI 1.12-1.43, p < 0.001), respiratory failure (OR = 2.73, 95%CI1.28-5.84, p = 0.010), renal failure (OR = 4.13, 95%CI1.93-8.83, p < 0.001), septic shock (OR = 8.77, 95%CI3.60-21.32, p < 0.001), mechanical ventilation (OR = 4.41, 95%CI1.59-12.25, p = 0.004) and CRKP infection (OR = 3.04, 95%CI1.28-7.22, p = 0.012) were independently associated with 28-day mortality.

CONCLUSIONS

Considerable incidence rate and remarkable mortality of patients with K. pneumoniae (especially CRKP) BSI was declared in the study. Patient conditions before (higher CCI) and after presentation (respiratory failure, renal failure, septic shock), and healthcare factors (mechanical ventilation and CRKP infection) were independently associated with 28-day mortality. Understanding these risks helps better establishment of infection control strategies.

Risk Factors for Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infections and Outcomes

Purpose

The incidence of carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infections (BSIs) is increasing globally; however, little has been reported on the risk factors and outcomes of CRKP BSIs in central China. This study aimed to determine the clinical risk factors for CRKP BSIs and the outcomes of CRKP BSIs.

Patients and Methods

We performed a case-control study of 239 patients with K. pneumoniae BSIs who were treated at Henan Provincial People’s Hospital between July 2017 and July 2018. The cases (n=98, 41%) had CRKP BSIs, and the controls (n=141, 59%) had non-carbapenem-resistant K. pneumoniae (non-CRKP) BSIs. Antimicrobial sensitivity was determined using automated broth microdilution and an agar disk diffusion method. Data were obtained from clinical and laboratory records. Multivariate logistic regression and Pearson chi-square tests were used to identify clinical factors and outcomes associated with carbapenem resistance.

Results

Risk factors for carbapenem resistance included recent carbapenem use (odds ratio [OR]: 9.98, 95% confidence interval [CI]: 5.2–17.1, P<0.001), invasive procedures (OR: 11.1, 95% CI: 3.3–37.7, P<0.001), and pre-existing diseases of the digestive system (OR: 8.22, 95% CI: 1.73–39.2, P=0.008). Treatment failure was more frequent in the cases (84.7%) than in the controls (32.6%).

Conclusion

Exposure to antibiotics, especially carbapenems, and invasive procedures were the major risk factors for carbapenem resistance among patients with K. pneumoniae BSIs. Strict control measures should be implemented to prevent the emergence and spread of CRKP.

Reduced Incidence of Carbapenem-Resistant Klebsiella pneumoniae Infections in Cardiac Surgery Patients after Implementation of an Antimicrobial Stewardship Project

Infections due to carbapenem-resistant Klebsiella pneumoniae (CR-Kp) are associated with increased mortality in cardiac surgery patients. In this short communication, we report on the changes in the incidence of CR-Kp colonization and CR-Kp infection in cardiac surgery patients from 2014 to 2018 in a teaching hospital in Italy, after the implementation of an antimicrobial stewardship project in 2014. During the study period, 2261 patients underwent open-heart surgery. Of them, 130 were found to be colonized by CR-Kp (5.7%) and 52 developed a postoperative CR-Kp infection (2.3%). The crude in-hospital mortality in patients with CR-Kp infections was 48% (25/52). The incidences of both CR-Kp colonization (incidence rate ratio (IRR) 0.82, 95% confidence intervals (CI) 0.78-0.86, p < 0.001) and CR-Kp infection (IRR 0.76, 95% CI 0.69-0.83, p < 0.001) considerably decreased over the study period. This encouraging result should prompt further concerted efforts, directed towards retaining the positive impact of stewardship and infection-control interventions on CR-Kp-related morbidity in the long term.