Carbapenem-resistant Enterobacteriaceae Acquisition Research Articles

Clinical Characteristics and Associated Factors for Mortality in Patients with Carbapenem-Resistant Enterobacteriaceae Bloodstream Infection.

Bloodstream infection (BSI) caused by carbapenem-resistant Enterobacteriaceae (CRE) significantly influences patient morbidity and mortality. We aimed to identify the characteristics, outcomes, and risk factors of mortality in adult patients with CRE bacteremia and elucidate the differences between carbapenemase-producing (CP)-CRE BSI and non-CP-CRE BSI. This retrospective study included 147 patients who developed CRE BSI between January 2016 and January 2019 at a large tertiary care hospital in South Korea. The patient demographic characteristics and clinical and microbiological data including the Enterobacteriaceae species and carbapenemase type were obtained and analyzed. Klebsiella pneumoniae was the most commonly detected pathogen (80.3%), followed by Escherichia coli (15.0%). In total, 128 (87.1%) isolates were found to express carbapenemase, and most CP-CRE isolates harbored blaKPC. The 14-day and 30-day mortality rates for CRE BSI were 34.0% and 42.2%, respectively. Higher body mass index (odds ratio (OR), 1.123; 95% confidence interval (CI), 1.012-1.246; p = 0.029), higher sequential organ failure assessment (SOFA) score (OR, 1.206; 95% CI, 1.073-1.356; p = 0.002), and previous antibiotic use (OR, 0.163; 95% CI, 0.028-0.933; p = 0.042) were independent risk factors for the 14-day mortality. A high SOFA score (OR, 1.208; 95% CI; 1.081-0.349; p = 0.001) was the only independent risk factor for 30-day mortality. Carbapenemase production and appropriate antibiotic treatment were not associated with high 14- or 30-day mortality rates. Mortality from CRE BSI was related to the severity of the infection rather than to carbapenemase production or antibiotic treatment, showing that efforts to prevent CRE acquisition rather than treatment following CRE BSI detection would be more effective at reducing mortality.

Carbapenem-resistant Enterobacteriaceae infection in children less than one year old in an Asian medical center.

The emergence of carbapenem-resistant Enterobacteriaceae (CRE) is a threat to public health worldwide. This study aimed to determine the risk factors and outcomes for CRE colonization and infection in infants. Children aged <1 year hospitalized with CRE pathogens isolated from January 2016 to June 2019 were retrospectively analyzed. Demographic and clinical data were examined. A total of 48 infections were identified in 70 infants aged <1 year, and 66.7% (32/48) of these infants were born preterm. The infection rate in infants aged <1 month was higher than that of others (P=0.005). The most commonly isolated CRE was Klebsiella pneumoniae (60.4%, 29/48), followed by Enterobacter cloacae complex (18.8%, 9/48). Sputum (37.5%, 18/48), blood (27.1%, 13/48), and urine (25.0%, 12/48) were the most common clinical samples. Urinary tract infection was common in infants aged 6-12 months. CRE infection was associated with mechanical ventilation (P=0.037), central venous catheter (CVC) insertion (P=0.034), and congenital heart disease (P=0.027). The hospital stay of patients with CRE infection was longer (median, 75 days; SD, 66.4 days), and their all-cause mortality (6.4%) was higher than those with colonization. CRE infection was common in infants aged <1 month, and patients usually had longer hospitalization. Carbapenemase production was not common. Mechanical ventilation, CVC insertion, and congenital heart disease were associated with a higher risk of CRE acquisition in infants aged <1 year.

High frequency of carbapenem-resistant Enterobacteriaceae fecal carriage among ICU hospitalized patients from Southern Iran.

The worldwide emergence of carbapenem-resistant Enterobacteriaceae (CRE) has become a major therapeutic concern to medical institutions. To date, no study has determined the frequency and risk factors of inpatients with CRE fecal carriage in Southern Iran. We studied the features of carbapenemase-producing Enterobacteriaceae (CPE) collected from the central ICU of a university hospital. Totally, 173 samples, including 124 stool samples from 46 ICU inpatients on admission and different follow-ups, 9 ICU staff, and 40 environmental samples were included. CRE was identified using microbiological methods. Antimicrobial susceptibility was investigated by using the disk diffusion method and E-test. Carbapenemase producers were detected using the mCIM method. Seven carbapenemase genes were characterized. The genetic relationship among 20 CPE was elucidated by PFGE. The overall fecal carriage rate was 28.2%, while CRE acquisition was 6.1%. CRE were classified as Klebsiella pneumoniae (71.4%), Escherichia coli (23.8%), and Enterobacter aerogenes (4.8%). From 21 CRE, 20 (95.2%) produced carbapenemases, of which 10, 15, 10, 25, 5, and 65% were blaKPC, blaSME, blaIMP, blaVIM, blaNDM and blaOXA-48-positive, respectively. Out of 20 CPE, 14 different PFGE patterns were observed, categorized into six clusters, suggestive of non-clonal spread. No difference between the examined risk factors with CRE carriage was shown. The data indicate a high CRE fecal carriage rate among inpatients. Our findings implicate the widespread of OXA-48 carbapenemase together with heterogeneity among CRE with great concern for dissemination and therapeutic threat. Early diagnosis and monitoring of CRE among inpatients are urgent.

Predictors of carbapenem-resistant Enterobacteriaceae (CRE) strains in patients with COVID-19 in the ICU ward: a retrospective case–control study

ObjectiveTo identify carbapenem-resistant Enterobacteriaceae (CRE) in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) and to determine whether they had different risk factors for the acquisition of CRE than patients without COVID-19.MethodsThis retrospective single-centre, case–control study enrolled patients with and without COVID-19. The demographic, clinical, infection, colonization and mortality data were compared between the two groups.ResultsA total of 38 patients with COVID-19 and 26 patients without COVID-19 were enrolled. The majority of isolates detected in COVID-19 patients were Klebsiella spp. Leukopenia at admission (odds ratio [OR] 4.70; 95% confidence interval [CI] 1.37, 16.10), invasive mechanical ventilation (OR 5.74; 95% CI 1.07, 30.63), carbapenem treatment (OR 5.09; 95% CI 1.21, 21.27) and corticosteroid treatment (OR 7.06; 95% CI 1.53, 32.39) were independent risk factors for CRE acquisition in COVID-19 patients. Intensive care unit (ICU) mortality was significantly higher in COVID-19 patients compared with patients without COVID-19 (OR 20.62; 95% CI 5.50, 77.23). Length of ICU stay increased the risk of death in patients with COVID-19 (subdistribution hazard ratio 3.81; 95% CI 1.33, 10.92).ConclusionCRE strains were more common in patients with COVID-19 and they had different risks for CRE compared with patients without COVID-19.

Genomically diverse carbapenem resistant Enterobacteriaceae from wild birds provide insight into global patterns of spatiotemporal dissemination

Carbapenem resistant Enterobacteriaceae (CRE) are a threat to public health globally, yet the role of the environment in the epidemiology of CRE remains elusive. Given that wild birds can acquire CRE, likely from foraging in anthropogenically impacted areas, and may aid in the maintenance and dissemination of CRE in the environment, a spatiotemporal comparison of isolates from different regions and timepoints may be useful for elucidating epidemiological information. Thus, we characterized the genomic diversity of CRE from fecal samples opportunistically collected from gulls (Larus spp.) inhabiting Alaska (USA), Chile, Spain, Turkey, and Ukraine and from black kites (Milvus migrans) sampled in Pakistan and assessed evidence for spatiotemporal patterns of dissemination. Within and among sampling locations, a high diversity of carbapenemases was found, including Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-beta-lactamase (NDM), oxacillinase (OXA), and Verona integron Metallo beta-lactamase (VIM). Although the majority of genomic comparisons among samples did not provide evidence for spatial dissemination, we did find strong evidence for dissemination among Alaska, Spain, and Turkey. We also found strong evidence for temporal dissemination among samples collected in Alaska and Pakistan, though the majority of CRE clones were transitory and were not repeatedly detected among locations where samples were collected longitudinally. Carbapenemase-producing hypervirulent K. pneumoniae was isolated from gulls in Spain and Ukraine and some isolates harbored antimicrobial resistance genes conferring resistance to up to 10 different antibiotic classes, including colistin. Our results are consistent with local acquisition of CRE by wild birds with spatial dissemination influenced by intermediary transmission routes, likely involving humans. Furthermore, our results support the premise that anthropogenically-associated wild birds may be good sentinels for understanding the burden of clinically-relevant antimicrobial resistance in the local human population.

Admission screening and cohort care decrease carbapenem resistant enterobacteriaceae in Vietnamese pediatric ICU\u2019s

ObjectivesTo assess if admission screening for Carbapenem Resistant Enterobacteriaceae (CRE) and cohort care can reduce CRE acquisition (CRE colonization during hospital stay), Hospital Acquired Infections (HAI), hospital-stay, mortality, and costs in three Intensive Care Units (ICU’s) at the Vietnamese National Children’s Hospital.MethodCRE screening using rectal swabs and ChromIDCarbas elective culture at admission and if CRE negative, once weekly. Patients were treated in cohorts based on CRE colonization status.ResultsCRE colonization at baseline point-prevalence screening was 76.9% (103/134). Of 941 CRE screened at admission, 337 (35.8%) were CREpos. 694 patients met inclusion criteria. The 244 patients CRE negative at admission and screened > 2 times were stratified in 8 similar size groups (periods), based on time of admission. CRE acquisition decreased significant (OR − 3.2, p < 0.005) from 90% in period 2 (highest) to 48% in period 8 (last period). Patients with CRE acquisition compared to no CRE acquisition had a significantly higher rate of culture confirmed HAI, n = 20 (14%) vs. n = 2 (2%), longer hospital stays, 3.26 vs. 2.37 weeks, and higher total treatment costs, 2852 vs. 2295 USD.ConclusionAdmission CRE screening and cohort care in pediatric ICU’s significantly decreased CRE acquisition, cases of HAI and duration of hospital-stay.

Risk factors of carbapenem-resistant Enterobacteriaceae infection and colonisation: a Malaysian tertiary care hospital based case-control study.

Carbapenem-resistant Enterobacteriaceae (CRE) infection has become a major challenge to clinicians. The aim of this study is to identify the risk factors of acquiring CRE to guide more targeted screening for hospital admissions. This is a retrospective case-control study (ratio 1:1) where a patient with CRE infection or colonisation was matched with a control. The control was an individual who tested negative for CRE but was a close contact of a patient testing positive and was admitted at the same time and place. Univariate and multivariate statistical analyses were done. The study included 154 patients. The majority of the CRE was Klebsiella species (83%). From univariate analysis, the significant risk factors were having a history of indwelling devices (OR: 2.791; 95% CI: 1.384-5.629), concomitant other MDRO (OR: 2.556; 95% CI: 1.144-5.707) and hospitalisation for more than three weeks (OR: 2.331; 95% CI: 1.163-4.673). Multivariate analysis showed that being unable to ambulate on admission (adjusted OR: 2.345; 95% CI: 1.170-4.699) and antibiotic exposure (adjusted OR: 3.515; 95% CI: 1.377-8.972) were independent predictors. The in-hospital mortality rate of CRE infection was high (64.5%). CRE acquisition resulted in prolonged hospitalisation (median=35 days; P<0.001). CRE infection results in high morbidity and mortality. On top of the common risk factors, patients with mobility restriction, prior antibiotic exposures and hospitalisation for more than three weeks should be prioritised in the screening strategy to control the spread of CRE.

Development of a Nomogram for Carbapenem-Resistant Enterobacteriaceae Acquisition Risk Prediction Among Patients in the Intensive Care Unit of a Secondary Referral Hospital

PurposeThis study aimed to identify the risk factors of carbapenem-resistant Enterobacteriaceae (CRE) acquisition to build a nomogram for CRE acquisition risk prediction and evaluate its performance. MethodsThis unmatched case-control study included 352 adult patients (55 patients and 297 controls) admitted to the intensive care unit (ICU) of a 453-bed secondary referral hospital between January 1, 2018, and September 31, 2019, in Busan, South Korea. The nomogram was built with the identified risk factors using multiple logistic regression analysis. Its performance was analyzed using calibration-in-the-large, the slope of the calibration plot, concordance statistic (c-statistic), and the sensitivity and specificity of the training set, subsets, and a new test set. ResultsThe risk factors of CRE acquisition among ICU patients at a secondary referral hospital were Acute Physiology and Chronic Health Evaluation II score at the time of admission, use of a central venous catheter and a nasogastric tube, as well as use of cephalosporin antibiotics. At 20.0% of the predicted CRE acquisition risk in the training set, the calibration-in-the-large was 0, slope of the calibration plot was 1, c-statistic was .93, sensitivity was 85.5%, and specificity was 84.8%. The performance was relatively good in the subsets and new test set. ConclusionThe nomogram can be used to monitor the CRE acquisition risk for ICU patients who have a similar case mix to patients in the study hospitals. Future studies need to involve more rigorous methodology and larger samples.

Epidemiology, risk factors and molecular analysis of carbapenem-resistant Enterobacteriaceae (CRE) in Mthatha, Eastern Cape, South Africa

Background: The emergence of carbapenem resistance in Enterobacteriaceae is an important threat to global health. Reported outcomes of infections with carbapenem-resistant Enterobacteriaceae (CRE) are poor. Commonly used antibiotics are generally inactive against CRE. Therefore, timely detection of CRE is of paramount importance. This study aimed to investigate the resistance genes responsible for CRE in Mthatha and to identify risk factors. Methods and materials: Study design – Prospective cohort study. Study period – 23 April to 27 September 2019. Setting – Eastern Cape province, SA. Study population – All adult and paediatric CRE patients. CRE case definition according to CDC 2018. ID and AST-bioMérieux Vitek 2 system. Detection of the blaOXA-48, blaKPC, blaNDM, and blaVIM by the RESIST-4 OKNV assay (Coris). Patients were interviewed to determine risk factors associated with CRE. Results: Forty-four non-duplicate CRE patients were identified during the study period from microbiology lab at NMAH. Enterobacteriaceae species: K. pneumoniae 22 (61.4%), E. cloacae 10 (22.7%), E. coli 2 (4.5%) and K. oxytoca, P. rettgeri and M. morganii 1 each (4.3%). Adult patient 29 (65.9%0 and paediatric 15 (34.1%). Race: all black patients except one white. CRE genes-blaOXA-48 22 (50%), blaNDM 8 (18.2%), two isolates (4.5%) with both blaOXA and blaNDM. We did not find any blaKPC and blaVIM in our setting and 12 (27.2%) isolates were negative for all OKNV. Outcomes: Demised 18 (40.9%), still admitted in the ward 1 (2.3%), discharged home on basis of clinical grounds 22 (50%) and 3 (6.8%) were transferred back to the district hospitals. HAI in 27 (61.4%) with VAP 8, HABSI 8, CAUTI 5, SSI 3 and CLABSI in 3. Risk factors for CRE acquisition were antibiotic exposure 25 (58.7%), ICU stay 7 (15.9%), received medical care in last 6 months 35 (79.6%) and none travelled outside RSA. HIV positive – 19 (43.2%). Conclusion: In out setting our CRE mortality rate is 40.9%, common CRE genotypes are blaOXA-48 and blaNDM. K. pneumoniae is the most common CRE-producing Enterobacteriaceae and antibiotic exposure is an important risk factor in Mthatha and surrounding areas.

Surgical site infection after liver transplantation in the era of multidrug-resistant bacteria: what new risks should be considered?

Surgical site infection (SSI) is a frequent infection site after liver transplantation (LT), and multidrug-resistant bacteria are common agents of those infections. This study aimed to analyze risk factors for SSI, including SSI caused by a multidrug-resistant microorganism (MDRO) after LT. We performed a cohort study of patients who underwent an LT from 2010 to 2018. The outcomes were SSI and SSI caused by MDRO. We analyzed features related to surgical procedure, patients' characteristics, and post-LT intercurrence. Surveillance for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Acinetobacter baumannii (CRAB) was performed through rectal swab at the LT admission and weekly until hospital discharge during all study periods. SSI was identified in 30.1% (229/762) of LTs. We observed a decline in the SSI rate from 37.5% in 2014 to 16.7% in 2018 (P 0.02). SSI caused by MDRO occurred in 109 (14.3%) patients. Klebsiella pneumoniae was the most common agent of both SSI and SSI caused by MDRO. The pre-LT colonization was 98 (12.9%) by CRE, 73 (9.6%) by VRE, and 28 (3.7%) by CRAB. Risk factors for SSI caused by MDRO identified were dialysis after LT (P 0.01), CRAB acquisition before LT (0.03), and CRE acquisition before LT (P 0.004); use of adjusted prophylaxis by MDRO risk was the only protective factor identified (P 0.01). MDROs were frequent agents of SSI after LT, and the carbapenem-resistant Gram-negative colonization before LT increased the risk of SSI by these agents.

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

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.

Risk Factors of Carbapenem-resistant Enterobacteriaceae Acquisition at a Community-based Hospital

Risk Factors of Carbapenem-resistant <i>Enterobacteriaceae</i> Acquisition at a Community-based Hospital

National Policy for Carbapenem-Resistant Enterobacteriaceae (CRE) Clearance and Discontinuation of Contact Precautions for CRE Carriers in Post-Acute Care Hospitals in Israel: Impact on Isolation-Days and New Acquisitions.

In 2009, the Israeli Ministry of Health implemented in post-acute care hospitals (PACHs) a process of discontinuing carbapenem-resistant Enterobacteriaceae (CRE) carrier status. We evaluated the policy's impact on isolation-days, CRE prevalence among known carriers who had completed clearance testing, and CRE acquisition among noncarriers. This retrospective study summarized findings from all 15 PACHs in 2009-2017. CRE carriers were considered cleared and removed from contact isolation after 2 rectal cultures negative for CRE and polymerase chain reaction negative for carbapenemases. Data sources included routine surveillance and 4 point prevalence surveys conducted from 2011 to 2017. During the study period, 887 of 6101 CRE carriers (14.5%) completed clearance testing. From 2013 to 2016, the percentage of patient-days in CRE isolation decreased from 9.4% to 3.9% (P = .008). In all surveys combined, there were 819 known CRE carriers; 411 (50%) had completed clearance testing. Of these, 11.4% (47/411) were CRE positive in the survey. At the ward level, the median percentage of patients with no CRE history who were positive on survey decreased from 11.3% in 2011 to 0% in 2017 (P < .001). We found no ward-level correlation between the proportion of carriers who completed clearance and new acquisitions (ρ = 0.02, P = .86). A process for discontinuing CRE carrier status in PACHs led to a significant reduction in the percentage of patient-days in contact isolation without increasing CRE acquisitions among noncarriers.

External Validation of Carbapenem-Resistant Enterobacteriaceae Acquisition Risk Prediction Model in a Medium Sized Hospital

This study was aimed to evaluate the external validity of a carbapenem-resistant Enterobacteriaceae (CRE) acquisition risk prediction model (the CREP-model) in a medium-sized hospital. This retrospective cohort study included 613 patients (CRE group: 69, no-CRE group: 544) admitted to the intensive care units of a 453-beds secondary referral general hospital from March 1, 2017 to September 30, 2019 in South Korea. The performance of the CREP-model was analyzed with calibration, discrimination, and clinical usefulness. The results showed that those higher in age had lower presence of multidrug resistant organisms (MDROs), cephalosporin use ≥ 15 days, Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥ 21 points, and lower CRE acquisition rates than those of CREP-model development subjects. The calibration-in-the-large was 0.12 (95% CI: - 0.16~0.39), while the calibration slope was 0.87 (95% CI: 0.63~1.12), and the concordance statistic was .71 (95% CI: .63~.78). At the predicted risk of .10, the sensitivity, specificity, and correct classification rates were 43.5%, 84.2%, and 79.6%, respectively. The net true positive according to the CREP-model were 3 per 100 subjects. After adjusting the predictors' cutting points, the concordance statistic increased to .84 (95% CI: .79~.89), and the sensitivity and net true positive was improved to 75.4%. and 6 per 100 subjects, respectively. The CREP-model's discrimination and clinical usefulness are low in a medium sized general hospital but are improved after adjusting for the predictors. Therefore, we suggest that institutions should only use the CREP-model after assessing the distribution of the predictors and adjusting their cutting points.

2439. The role of positive externalities in economic evaluations of new antibiotics: modeling the impact of reduced transmission in healthcare facilities

BackgroundPositive externalities - beneficial spillover effects enjoyed by individuals who are not the primary consumers of a good - are rarely considered in cost-effectiveness analyses (CEAs) of antimicrobial drugs that could reduce person-to-person transmission of the target pathogen. We developed a compartmental model to simulate the effect of 2 hypothetical antibiotics targeting carbapenem-resistant Enterobacteriaceae (CRE) among hospital inpatients: one that treats bloodstream infections (BSIs) and one that decolonizes carriers. We assessed the contribution of positive externalities to the results of CEAs of these 2 antibiotics in the model.MethodsOur model tracked patients according to CRE carriage, clinical infection, and detection status. Rates of CRE acquisition depended on transmissibility of carriers in different states and were calibrated to data from long-term acute care hospitals. For the BSI treatment scenario we assumed the new drug would decrease the death rate and transmissibility of patients after CRE BSI onset. For the decolonization scenario we assumed the new drug would increase clearance of CRE carriage after clinical detection. For each scenario, we quantified the drug’s effect on the number of BSIs and deaths among patients receiving the drug (direct effect) and among all patients (total effect, i.e., direct plus indirect effect) compared with usual care. For the CEAs, the effectiveness outcome was life-years (LYs) gained and we assumed the new drug cost of $4,000 per dose and cost of a CRE BSI of $24,788.ResultsFor both the BSI treatment and decolonization scenarios, the total effect of introducing the new drug was greater than the direct effect alone, indicating the existence of positive externalities. Relative to usual care, the new drug led to a decrease in incremental cost and an increase in incremental effectiveness (see Figures 1 and 2).ConclusionThe inclusion of positive externalities in CEAs can have important effects on whether these new antibiotics are deemed cost-effective, due to their potential for interrupting chains of transmission. In our model, the inclusion of these effects reduced the incremental cost and increased the incremental effectiveness of these antibiotics. Disclosures All authors: No reported disclosures.

1223. Endoscopic Retrograde Cholangiopancreatography (ERCP)-Associated Carbapenem-resistant Enterobacteriaceae (CRE) Before and After Implementation of Ethylene Oxide (ETO) Sterilization of Duodenoscopes

BackgroundReusable duodenoscopes utilized for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures are challenging to clean thoroughly. Outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) have been associated with the use of duodenoscopes even when no clear breaches in manufacturer-recommended manual cleaning and high-level disinfection have been found. We evaluate the impact of implementation of ethylene oxide (ETO) sterilization on rates of ERCP-associated CRE.MethodsThe charts of all patients who developed CRE colonization or infection between 2012 and 2018 in a large tertiary care teaching hospital were reviewed to determine whether the patient had an ERCP in the 90 days prior to the CRE culture date. Rates of CRE acquisition per 100 ERCPs performed were calculated and compared pre (ERCP performed January 2012 through February 2015) and post-implementation (ERCP performed March 2015 thru December 2018) of routine ETO sterilization of duodenoscope following high-level disinfection (HLD) with an automatic endoscope reprocessor (AER) rather than HLD alone.ResultsBetween 2012 and 2018, 44 patients had first clinical culture with CRE within 90 days of ERCP (36% blood, 34% wound/surgical, 25% urinary and 7% respiratory sources). ETO sterilization of duodenoscopes following manufacturer recommended HLD was implemented March 2015. Rates of first CRE clinical culture within 90 days of ERCP decreased from 0.80 with HLD alone to 0.25 per 100 ERCP procedures with HLD plus ETO (unadjusted IRR 0.31 ETO vs. HLD alone, 95% CI 0.16–0.57, p-value < 0.001). This decrease occurred despite implementation of updated CLSI carbapenem breakpoints in July 2016. Figure 1 shows post ERCP CRE clinical culture trends over timeConclusionImplementation of ETO sterilization for duodenoscopes following HLD reduced our rates of post ERCP CRE in clinical cultures within 90 days of the procedure. Disclosures All authors: No reported disclosures.

Epidemiology and risk factors for carbapenem-resistant Enterobacteriaceae colonisation and infections: case-controlled study from an academic medical center in a southern area of China.

While the emergence and spread of carbapenem-resistant Enterobacteriaceae (CRE) and related infections pose serious threats to global public health, the epidemiology and associated risk factors remain poorly understood and vary by geography. In a case-controlled retrospective study, we examined the prevalence, patient background and risk factors for CRE colonisation and infections, and all patient-derived CRE from January 2015 to January 2017. Isolated carbapenem-susceptible Enterobacteriaceae (CSE) from 2875 enrolled patients were randomly selected during the study. CRE colonisation and infections detection rates were 47/2875 (1.6%). Respiratory tract specimens were most frequently seen in 20/47 (42.6%) cases. Klebsiella pneumoniae was the main isolate in 35/47 (74.5%) CRE. As for carbapenemase, KPC-2-producing bacteria was most frequently detected in 38/47 (80.9%) Enterobacteriaceae. No underlying conditions (P=0.004), pulmonary diseases (P=0.018) and no antibiotics used prior to culture within 30 days (P<0.001) were statistically significant between the CRE and CSE groups. Klebsiellapneumoniae was the main isolate of CRE. The blaKPC-2 was the predominant CRE gene. Underlying conditions especially pulmonary diseases and antibiotics used prior to culture within 30 days represented key risk factors for acquisition of CRE.

High prevalence of colonisation with carbapenem-resistant Enterobacteriaceae among patients admitted to Vietnamese hospitals: Risk factors and burden of disease

Carbapenem-resistant Enterobacteriaceae (CRE) is an increasing problem worldwide, but particularly problematic in low- and middle-income countries (LMIC) due to limitations of resources for surveillance of CRE and infection prevention and control (IPC). A point prevalence survey (PPS) with screening for colonisation with CRE was conducted on 2233 patients admitted to neonatal, paediatric and adult care at 12 Vietnamese hospitals located in northern, central and southern Vietnam during 2017 and 2018. CRE colonisation was determined by culturing of faecal specimens on selective agar for CRE. Risk factors for CRE colonisation were evaluated. A CRE admission and discharge screening sub-study was conducted among one of the most vulnerable patient groups; infants treated at an 80-bed Neonatal ICU from March throughout June 2017 to assess CRE acquisition, hospital-acquired infection (HAI) and treatment outcome. A total of 1165 (52%) patients were colonised with CRE, most commonly Klebsiella pneumoniae (n = 805), Escherichia coli (n = 682) and Enterobacter spp. (n = 61). Duration of hospital stay, HAI and treatment with a carbapenem were independent risk factors for CRE colonisation. The PPS showed that the prevalence of CRE colonisation increased on average 4.2% per day and mean CRE colonisation rates increased from 13% on the day of admission to 89% at day 15 of hospital stay. At the NICU, CRE colonisation increased from 32% at admission to 87% at discharge, mortality was significantly associated (OR 5·5, P<0·01) with CRE colonisation and HAI on admission. These data indicate that there is an epidemic spread of CRE in Vietnamese hospitals with rapid transmission to hospitalised patients.

Epidemiology of carbapenem-resistant Enterobacteriaceae in a Tertiary Care Center in the Kingdom of Bahrain.

PURPOSE:The purpose of the study is to estimate the rate of infection with carbapenem-resistant Enterobacteriaceae (CRE) in the main governmental tertiary care hospital in Bahrain.MATERIALS AND METHODS:All clinical samples with positive growth of CRE over 6-year period (January 2012–December 2017) were collected from the microbiology laboratory data.RESULTS:The CRE incidence was high in the first half of study period (2012–2014) and then decreased between 2015 and 2017, after implementation of intensified CRE control measure bundle. About 49.4% of CRE-positive samples were isolated from the elderly age group (above 65 years old), most of them were admitted in the intensive care unit (ICU). The most common isolated organisms were Klebsiella pneumoniae (87.0%), followed by Escherichia coli (7.9%). Isolates from deep tracheal aspirate and midstream urine specimens were the most common source of CRE isolates (27.3%) and (26.3%), respectively. Bacteremia was documented in 21.2% of cases. CRE isolates in the study showed high rates of resistance to aminoglycosides (72.2% resistant to amikacin and 67.3% to gentamicin). Alternatively, most isolates retained their susceptibility to colistin and tigecycline with sensitivity of 83.9% and 85.7%, respectively. Combined resistance to both colistin and tigecycline was observed in 0.06% of total isolates.CONCLUSION:Elderly population and ICU admission were important risk factors for CRE acquisition. Most of CRE isolates were sensitive to both colistin and tigecycline, which make them the best combination for empiric frontline therapy for suspected serious CRE infection in our facility. Implementing CRE-bundled infection control measures significantly reduced the incidence of CRE infection in our hospital.

Prevalence and Risk Factors of Carbapenem-resistant Enterobacteriaceae Acquisition in an Emergency Intensive Care Unit in a Tertiary Hospital in Korea: a Case-Control Study.

BackgroundInfections caused by carbapenem-resistant Enterobacteriaceae (CRE) are associated with high mortality rates and their treatment is difficult because treatment is limited to certain antibiotics, such as colistin and tigecycline. We aimed to perform active surveillance culture of CRE (ASC-CRE) to monitor the prevalence of CRE acquisition during intensive care unit (ICU) care and to examine the potential risk factors associated with CRE acquisition.MethodsWe conducted ASC-CRE on patients who were admitted to the ICU in the emergency room at a tertiary hospital. Rectal swabs were analyzed using methods established by the Centers for Disease Control and Prevention. To detect carbapenemase-producing CRE, a polymerase chain reaction assay to detect five carbapenemase genes (blaNDM, blaKPC, blaVIM, blaIMP-1, and blaOXA-48) was performed.ResultsThere were 22 CRE acquisition in 21 patients (2.6%, 21/810) and the incidence of CRE acquisition was 4.3/1,000 person-days, respectively. The most common species detected was Klebsiella pneumoniae (72.7%, 16/22), and 9 carbapenemase-producing CREs (7 blaKPC and 2 blaNDM) were detected. Independent risk factors associated with CRE acquisition were men gender (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 1.3–21.3), history of admission within one year (aOR, 3.9; 95% CI, 1.2–12.1), co-colonization with multidrug-resistant Acinetobacter baumannii (aOR, 15.6; 95% CI, 3.6–67.8) and extended-spectrum β-lactamases-producing bacteria (aOR, 4.7; 95% CI, 1.5–14.6), and exposure to glycopeptide antibiotics (aOR, 3.6; 95% CI, 1.3–9.9).ConclusionThe identification of patients with risk factors for CRE acquisition and early detection of CRE acquisition using ASC-CRE may be useful for CRE control.