Abstract
BackgroundCarbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant nosocomial pathogen, spreading to hospitalized elderly patients. Risk factors in this setting are unclear. Our aims were to explore the contribution of multi-morbidity and disease severity in the onset of CRKP colonization/infection, and to describe changes in epidemiology after the institution of quarantine-ward managed by staff-cohorting.Methods and FindingsWith a case-control design, we evaluated 133 CRKP-positive patients (75 M, 58 F; mean age 79±10 years) and a control group of 400 CRKP-negative subjects (179 M, 221 F; mean age 79±12 years) admitted to Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, during a 10-month period. Information about comorbidity type and severity, expressed through Cumulative Illness Rating Scale-CIRS, was collected in each patient. During an overall 5-month period, CRKP-positive patients were managed in an isolation ward with staff cohorting. A contact-bed isolation approach was established in the other 5 months. The effects of these strategies were evaluated with a cross-sectional study design. CRKP-positive subjects had higher CIRS comorbidity index (12.0±3.6 vs 9.1±3.5, p<0.0001) and CIRS severity index (3.2±0.4 vs 2.9±0.5, p<0.0001), along with higher cardiovascular, respiratory, renal and neurological disease burden than control group. CIRS severity index was associated with a higher risk for CRKP-colonization (OR 13.3, 95%CI6.88–25.93), independent of comorbidities. Isolation ward activation was associated with decreased monthly incidence of CRKP-positivity (from 16.9% to 1.2% of all admissions) and infection (from 36.6% to 22.5% of all positive cases; p = 0.04 derived by Wilcoxon signed-rank test). Mortality rate did not differ between cases and controls (21.8% vs 15.2%, p = 0.08). The main limitations of this study are observational design and lack of data about prior antibiotic exposure.ConclusionsComorbidities and disease severity are relevant risk factors for CRKP-colonization/infection in elderly frail patients. Sanitary measures may have contributed to limit epidemic spread and rate of infection also in internal medicine setting.
Highlights
In the era of antibiotic resistance and multi-drug resistant bacteria, the emergence and spread of carbapenem-resistant Klebsiella pneumoniae (CRKP), known as carbapenemaseproducing Klebsiella pneumoniae, has rapidly become a major health concern for hospitalized patients in industrialized countries [1]
With a cross-sectional study design, we have described the changes in Carbapenem-resistant Klebsiella pneumoniae (CRKP) epidemic trend and rate of infection occurred after the institution of special sanitary measures, namely quarantine ward with staff cohorting management
CRKP-positive patients had a large number of comorbidities with a high degree of clinical complexity, as attested by high values of Cumulative Illness Rating Scale (CIRS) comorbidity and CIRS severity indexes (Table 1)
Summary
In the era of antibiotic resistance and multi-drug resistant bacteria, the emergence and spread of carbapenem-resistant Klebsiella pneumoniae (CRKP), known as carbapenemaseproducing Klebsiella pneumoniae, has rapidly become a major health concern for hospitalized patients in industrialized countries [1]. Klebsiella pneumoniae is the most frequent bacterial species associated with production of high-affinity carbapenemases. Their genes typically reside on transferable plasmids and are conventionally known as KPC. Recent national data showed that CRKP is more frequently isolated from patients outside intensive care units (ICU), often admitted to geriatric or internal medicine wards [9,10,11]. Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant nosocomial pathogen, spreading to hospitalized elderly patients. Risk factors in this setting are unclear. Our aims were to explore the contribution of multi-morbidity and disease severity in the onset of CRKP colonization/infection, and to describe changes in epidemiology after the institution of quarantine-ward managed by staff-cohorting
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