Screening for Extended-Spectrum -Lactamase-Producing Enterobacteriaceae among High-Risk Patients and Rates of Subsequent Bacteremia

Abstract

Bloodstream infections due to extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae have been associated with increased hospital costs, length of stay, and patient mortality. However, the role of routine inpatient surveillance for ESBL colonization in predicting related infection is unclear. From 2000 through 2005, we screened 17,872 patients hospitalized in designated high-risk units for rectal colonization with vancomycin-resistant enterococci and ESBL-producing Enterobacteriaceae using a selective culture medium. In patients with a bloodstream infection due to ESBL-producing Enterobacteriaceae (ESBL-BI) during the study period, surveillance results were evaluated for evidence of antecedent ESBL-producing Enterobacteriaceae colonization. The rate of ESBL-producing Enterobacteriaceae colonization doubled during the 6-year study period, increasing from 1.33% of high-risk patients in 2000 to 3.21% in 2005. Among patients with ESBL-producing Enterobacteriaceae colonization, 49.6% also carried vancomycin-resistant enterococci. The number of ESBL-BIs increased >4-fold in 5 years, from 9 cases in 2001 to 40 cases in 2005. Of 413 patients colonized with ESBL-producing Enterobacteriaceae, 35 (8.5%) developed a subsequent ESBL-BI. Of concern, more than one-half of all ESBL-BIs occurred in patients who were not screened. These 56 patients received a diagnosis of ESBL-BI in the emergency department, when hospitalized in low-risk medical units, or at transfer from an acute or long-term health care facility. Colonization with ESBL-producing Enterobacteriaceae is increasing at a rapid rate, and routine rectal surveillance for ESBL-producing Enterobacteriaceae may have clinical implications. However, in our experience, over one-half of patients with an ESBL-BI did not undergo screening through our current surveillance measures. As a result, targeted screening for ESBL-producing Enterobacteriaceae among additional patient populations may be integral to future ESBL-BI prevention and management efforts.