Antimicrobial Stewardship Program, COVID-19, and Infection Control: Spread of Carbapenem-Resistant Klebsiella Pneumoniae Colonization in ICU COVID-19 Patients. What Did Not Work?

Beatrice Tiri,Emanuela Sensi,Stefano Cappanera,Mizar Cantarini,Alessandro Mariottini,Roberto Cirocchi,Monya Costantini,Paolo Bruzzone,Giulia Priante,Fabio Suadoni,Paolo Andreani,Carlo Vernelli,Marsilio Francucci,Viola Marsiliani,Lucia Assunta Martella

doi:10.3390/jcm9092744

Abstract

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the “daily-ICU round strategy” and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4–5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization.

Highlights

The European burden of disease associated with infections owing to antibiotic-resistant bacteria was very high as far as Italy was concerned, with 10,762 deaths in 2015 [1]
We analyzed bimonthly data from January–February 2019 to May–June 2020 concerning the number of patients admitted to the intensive care unit (ICU) and number of rectal carriers of Carbapenem-Resistant Enterobacteriaceae (CRE) (Table 1)
The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for the management of infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospital patients define the implementation of hand hygiene education programmes, contact precautions, use of alert code to identify promptly patients colonized by CRE, isolate colonized and infected patients, implementation of a programme of active screening culture, and implementation of an antimicrobial stewardship program as a strong recommendation [3]

Summary

Introduction

The European burden of disease associated with infections owing to antibiotic-resistant bacteria was very high as far as Italy was concerned, with 10,762 deaths in 2015 [1]. The European Centre for Disease Control (ECDC) reported that, in Europe, 7.5% of Klebsiella pneumoniae isolated from blood cultures and cerebral spinal fluid were resistant to carbapenems, while in Italy, it was 26.8% [4]. During the ECDC visit to Italy in order to discuss antimicrobial resistance (AMR) issues, it was reported that the AMR situation is one of the major Italian health problems, warning to urgently introduce measures for the appropriate use of the antibiotics and to improve infection control [5]. We report an observational retrospective analysis to evaluate the incidence of Carbapenem-Resistant Enterobacteriaceae (CRE) colonization and CRE acquisition in the ICU in pre-COVID-19 era, during the COVID-19 pandemic, and in post-COVID-19 era

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Discussion

Conclusion