Carbapenem-resistant Enterobacteriaceae Acquisition Research Articles

Risk factors for mortality among carbapenem-resistant enterobacteriaceae carriers with focus on immunosuppression

ObjectivesTo identify risk factors for mortality in a cohort of carbapenem-resistant enterobacteriaceae (CRE) carriers, focusing on immunosuppression and other risk factors known at the time of CRE carriage detection. MethodsWe prospectively followed all new and known CRE carriers admitted between June 2016 and June 2017 to a single tertiary center in Israel. Patients were included in the study after confirmation of the carrier state. Demographic and clinical data were documented on admission or CRE acquisition and patients were followed prospectively post-discharge until January 2018 or death. Risk factors for mortality known at the time of the first encounter with a CRE carrier were sought. Adjusted hazard ratios (HR) for mortality at end of follow-up with 95% confidence intervals (CI) were assessed using Cox regression analysis. ResultsA total of 115 patients were included in the analysis. During the study period, 66 (57.4%) patients died. Immunosuppression was associated with mortality (HR 1.95, CI 95% 1.12–3.44), adjusted to the Charlson co-morbidity score, functional status, chronic renal disease and Klebsiella pneumonia CRE, the latter three also significantly associated with mortality. CRE bacteremia occurred among 24 (20.9%) carriers during follow up, more frequently among immunosuppressed patients and was significantly associated with mortality at end of follow-up (p = 0.015). ConclusionImmunosuppression is independently associated with mortality among CRE carriers, possibly related to CRE bacteremia that is frequent among these patients. Further research is needed on interventions to prevent deaths among CRE carriers.

The epidemiology and risk factor of carbapenem-resistant enterobacteriaceae colonization and infections: Case control study in a single institute in Japan.

While the emergence and spread of carbapenem-resistant enterobacteriaceae (CRE) carriage and infections are serious threats to public health worldwide, its prevalence and epidemiology are still unknown. For the purpose of examining the prevalence, patients' background and risk factors for CRE carriage and infections, we conducted this case-control study. We retrospectively reviewed all patients isolating CRE at Aichi Medical University hospital from January 2010 until March 2017. The patients isolated with carbapenem-susceptible enterobacteriaceae (CSE) were randomly selected during the study period. A total of 26 patients, isolating 28 CRE infections were enrolled in this study. The detection rate of CRE carriage and infection was 0.22% (28/12,600). Compared to the CSE group, the CRE group had poorer PS and higher CCI scores. The CRE group tended to stay longer in hospital (121 v.s. 63 days, p=0.052) and admission fee was much more expensive than CSE group (220,710 v.s. 69,904 JPY, p<0.001). PS 2-4 (ECOG) and CCI≧3 (p=0.002), prior hospitalization within 90 days (p=0.006) and prior antibiotics use within 90 days (p=0.005) were risk factors for acquisition of CRE by univariate analysis. The combination of PS 2-4 and CCI≧3 was an independent risk factor for CRE carriage and infection by multivariate logistic regression analysis. The combination of PS 2-4 (ECOG) and CCI score≧3 was an independent risk factor of CRE carriage and infections. The CRE group tended to stay longer in hospital, and the medical expense was much more expensive than those in the CSE group.

Factors associated with acquisition of carbapenem-resistant Enterobacteriaceae.

ABSTRACTObjective:to identify possible risk factors for acquisition of Enterobacterial strains with a marker for resistance to carbapenems. Methods:exploratory case-control study performed in hospital settings. The study sample consisted of patients with biological specimens that tested positive for carbapenem-resistant Enterobacteriaceae (cases), with the disk diffusion test and Etest, and controls with biological samples testing negative for carbapenem-resistant Enterobacteriaceae. In all, 65 patients were included: 13 (20%) cases and 52 (80%) controls. Results:the microorganisms isolated were Serratia marcescens (6), Klebsiella pneumoniae (4), and Enterobacter cloacae (3). Univariate analysis revealed that length of hospitalization prior to sample collection (p=0.002) and having a surgical procedure (p=0.006) were statistically significant. In the multivariable logistic regression model, both were still significant, with odds ratios of 0.93 (p = 0.009; 95% CI: 0.89 to 0.98) for length of hospitalization prior to sample collection, and 9.28 (p = 0.05; 95% CI: 1.01 to 85.14) for having a surgical procedure. Conclusion:shorter hospitalization times and increased surveillance of patients undergoing surgery could play a decisive role in reducing the spread of carbapenem-resistant microorganisms in hospital settings.

Carbapenem-Resistant Enterobacteriaceae Acquired Before Liver Transplantation: Impact on Recipient Outcomes.

Carbapenem-resistant Enterobacteriaceae (CRE) is an emergent microorganism of infections after liver transplant (LT). The aim of this study was to analyze the risk factors for CRE acquisition and infection after LT. This was a prospective cohort study involving patients who underwent LT in the 2010 to 2014 period. Surveillance cultures for CRE were collected immediately before LT and weekly thereafter until hospital discharge. We analyzed 386 patients undergoing a total of 407 LTs. Before LT, 68 (17.6%) patients tested positive for CRE, 11 (16.2%) of those patients having CRE infection, whereas 119 (30.8%) patients acquired CRE after LT. Post-LT CRE infection was identified in 59 (15.7%) patients: Klebsiella pneumoniae was isolated in 83.2%; surgical site infection was the most common type of infection (46.7%). Multivariate analysis showed that post-LT dialysis was the only risk factor for post-LT CRE acquisition. Eighty-two percent of patients who underwent 3 or more post-LT dialysis sessions and acquired CRE before LT evolved with post-LT CRE infection. Other risk factors for CRE infection were acquisition of CRE post-LT, Model for End-Stage Liver Disease score greater than 32, combined transplantation, and reoperation. Patients who acquired CRE before LT had a high risk of developing CRE infection (P < 0.001). Measures for minimizing that risk, including altering the antibiotic prophylaxis, should be investigated and implemented.

Carbapenem-resistant Enterobacteriaceae: Prevalence and Risk Factors in a Single Community-Based Hospital in Korea.

BackgroundCarbapenemase-producing Enterobacteriaceae (CPE) are Gram-negative bacteria with increasing prevalence of infection worldwide. In Korea, 25 cases of CPE isolates were reported by the Korea Centers for Disease Control and Prevention in 2011. Most CPE cases were detected mainly at tertiary referral hospitals. We analyzed the prevalence and risk factors for carbapenem-resistant Enterobacteriaceae (CRE) in a mid-sized community-based hospital in Korea.Materials and MethodsWe retrospectively analyzed all consecutive episodes of Enterobacteriaceae in a mid-sized community-based hospital from January 2013 to February 2014. CRE was defined as organisms of Enterobacteriaceae showing decreased susceptibility to carbapenems. Risk factors for CRE were evaluated by a case–double control design. Carbapenemase was confirmed for CRE using a combined disc test.ResultsDuring 229,710 patient-days, 2,510 Enterobacteriaceae isolates were obtained. A total of 41 (1.6%) CRE isolates were enrolled in the study period. Thirteen species (31.7%) were Enterobacter aerogenes, 8 (19.5%) Klebsiella pneumoniae, 5 (12.2%) Enterobacter cloacae, and 15 other species of Enterobacteriaceae, respectively. Among the 41 isolates, only one (2.4%) E. aerogenes isolate belonged to CPE. For evaluation of risk factors, a total of 111 patients were enrolled and this included 37 patients in the CRE group, 37 in control group I (identical species), and 37 in control group II (different species). Based on multivariate analysis, regularly visiting the outpatient clinic was a risk factor for CRE acquisition in the control group I (P = 0.003), while vascular catheter and Charlson comorbidity index score ≥ 3 were risk factors in control group II (P = 0.010 and 0.011, each). Patients with CRE were more likely to experience a reduced level of consciousness, use a vasopressor, be under intensive care, and suffer from acute kidney injury. However, CRE was not an independent predictor of mortality compared with both control groups.ConclusionIn conclusion, the prevalence of CRE was higher than expected in a mid-sized community-based hospital in Korea. CRE should be considered when patients have a vascular catheter, high comorbidity score, and regular visits to the outpatient clinic. This study suggests the need for appropriate prevention efforts and constant attention to CRE infection control in a mid-sized community-based hospital.

Risk factors for acquisition of carbapenem resistant Enterobacteriaceae in an acute tertiary care hospital in Singapore.

BackgroundCarbapenem resistant Enterobacteriaceae (CRE) is increasingly reported worldwide. A similar increase is seen in Singapore since identification of its first case in 2008. The aim of this study was to identify local risk factors for carriage of CRE in patients from an acute tertiary care hospital in Singapore.MethodA matched case-control study was conducted on inpatients treated from January 1, 2011 till December 31, 2013. Two hundred and three cases of CRE infection or colonization were matched with 203 controls. CRE types were identified by PCR. Statistical analysis of data including a multivariate logistic regression analysis was done using SPSS 21.0.ResultsCREs were commonly seen in Klebsiella pneumoniae (42.2 %), Escherichia coli (24.3 %) and Enterobacter cloacae complex (17.2 %) in the 268 isolates. NDM-1 was the commonest CRE type seen (44.4 %), followed by KPC (39.9 %) whilst OXA-48 only constituted (7.8 %). Univariate analysis identified key risk factors associated with CRE as history of previous overseas hospitalization (OR: 33.667; 95 % CI: 4.539-259.700), admission to ICU (OR: 11.899; 95 % CI: 4.986-28.399) and HD/ICA (OR: 6.557; 95 % CI: 4.057-10.596); whilst a multivariate analysis revealed exposure to antibiotics penicillin (OR: 4.640; 95 % CI: 1.529-14.079] and glycopeptide (OR: 5.162; 95 % CI: 1.377-19.346) and presence of central line device (OR: 3.117; 95 % CI: 1.167-8.330) as significant independent predictors.ConclusionsThe identification of risk factors amongst our local population helped to refine the criteria used for target active surveillance screening for CRE amongst inpatients at time of hospital admission.

Carbapenem-resistant Enterobacteriaceae carriers in acute care hospitals and postacute-care facilities: The effect of organizational culture on staff attitudes, knowledge, practices, and infection acquisition rates

Carbapenem-resistant Enterobacteriaceae (CRE) carriers are frequently transferred between acute care hospitals (ACHs) and postacute-care facilities (PACFs). Compliance of health care workers with infection prevention guidelines in both care settings may be influenced by the institution's organizational culture. To assess the association between organizational culture and health care workers' attitudes, knowledge, practices, and CRE acquisition rate and to identify differences between different care settings and health care workers' sectors. Cross-sectional descriptive design. Self-administered questionnaires were distributed to a sample of 420 health care workers from 1 ACH and 1 PACF belonging to the same health maintenance organization located in central Israel. The organizational culture factor known as staff engagement was positively correlated with infection prevention attitudes and compliance with contact precaution protocols and negatively correlated with CRE acquisition rate. In the 2 care settings, health care workers' attitudes, knowledge, and practices were found to be similar, but CRE acquisition rate was lower in PACFs. Compliance with contact precaution protocols by physicians was lower than compliance reported by other health care workers. Auxiliary staff reported lower knowledge. In a setting of endemic CRE where a multifaceted intervention is already being implemented, organizational culture variables can predict health care workers' attitudes, knowledge, and practices and in turn can affect CRE acquisition rates.

New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes.

Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities. To identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital. Outbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed. Association between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing. In total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producing Escherichia coli was recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008], P < .001). After the hospital changed its reprocessing procedure from automated high-level disinfection with ortho-phthalaldehyde to gas sterilization with ethylene oxide, no additional case patients were identified. In this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producing E coli among patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.

An Ongoing National Intervention to Contain the Spread of Carbapenem-Resistant Enterobacteriaceae

In 2007, the Israel Ministry of Health initiated a nationwide intervention aimed at containing the spread of carbapenem-resistant Enterobacteriaceae (CRE), primarily manifested by the rapid dissemination of a single clone of Klebsiella pneumoniae. Data were gathered from acute and long-term care facilities, and ward-based mandatory guidelines for carrier isolation, patient and staff cohorting, and active surveillance were issued. Guidelines were issued to the microbiology laboratories delineating procedures for identifying CRE and carbapenemase production. A protocol for ruling out continued carriage in known carriers was established. Compliance with national guidelines was overseen via site visits at healthcare facilities, routine reporting of carrier census and isolation status, and the establishment of a network of communications to facilitate reporting on identified carriage, contact tracing and screening, and outbreak investigations. During the intervention, nosocomial CRE acquisition in acute care declined from a monthly high of 55.5 to an annual low of 4.8 cases per 100,000 patient-days (P < .001).

Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae in Community Hospitals

The occurrence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing at an alarming rate worldwide. Despite that increase, there are limited data identifying risk factors. To evaluate risk factors associated with the acquisition of CRE among hospitalized patients. We performed a retrospective case-case-control study in 4 community hospitals from June 2007 through June 2012. Case group 1 (CG1) consisted of patients with CRE. Case group 2 (CG2) consisted of patients with carbapenem susceptible Enterobacteriaceae (CSE). CG2 patients were matched to CG1 patients by site of infection and species of Enterobacteriaceae. Hospitalized controls were matched 2:1 by date of admission and hospital location to patients in CG1. Two sets of analyses were conducted comparing demographics, comorbidities, and antibiotic exposures of CG1 and CG2 to controls and then contrasted to identify unique risk factors associated with CRE. Overall, 104 patients (CG1, 25 patients; CG2, 29 patients, control, 50 patients) were evaluated. CRE and CSE consisted mostly of Klebsiella spp. (63%) from a urinary source (28%). In multivariable analyses, intensive care unit (ICU) stay (OR 12.48; 95% CI 1.14-136.62; p = 0.04) and cumulative number of antibiotic days (OR 1.47; 95% CI 1.02-2.16; p = 0.04) were distinct independent predictors of CRE isolation; whereas, cumulative health care exposures (OR 2.03; 95% CI 1.20-3.41; p < 0.01) and vancomycin exposure (OR 6.70; 95% CI 1.15- 38.91; p = 0.03) were predictors for CSE. CRE should be considered in patients requiring ICU admission, particularly those who have received multiple antibiotics. Antibiotic stewardship efforts should be directed at reducing all antibiotic exposures as opposed to any specific antibiotic class to reduce the risk of CRE.

Prevalence and Risk Factors for Acquisition of Carbapenem-Resistant Enterobacteriaceae in the Setting of Endemicity

To describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) carriage and acquisition among hospitalized patients in an area of CRE endemicity. Cohort study with a nested case-control study. Two acute care, academic hospitals in New York City. All patients admitted to 7 study units, including intensive care, medical-surgical, and acute rehabilitation units. Perianal samples were collected from patients at admission and weekly thereafter to detect asymptomatic gastrointestinal carriage of CRE. A nested case-control study was performed to identify factors associated with CRE acquisition. Case patients were those who acquired CRE during a single hospitalization. Control subjects had no microbiologic evidence of CRE and at least 1 negative surveillance sample. Clinical data were abstracted from the medical record. The prevalence of CRE in the study population was 5.4% (306 of 5,676 patients), and 104 patients met the case definition of acquisition during a single hospital stay. Mechanical ventilation (odds ratio [OR], 11.5), pulmonary disease (OR, 5.2), days of antibiotic therapy (OR, 1.04), and CRE colonization pressure (OR, 1.15) were independently associated with CRE acquisition. Pulsed-field gel electrophoresis analysis identified 87% of tested Klebsiella pneumoniae isolates as sharing related patterns (greater than 78% similarity), which suggests clonal transmission within and between the study hospitals. Critical illness and underlying medical conditions, CRE colonization pressure, and antimicrobial exposure are important risk factors for CRE acquisition. Adherence to infection control practices and antimicrobial stewardship appear to be critical components of a CRE control program.

Deconstructing the infection control bundles for the containment of carbapenem-resistant Enterobacteriaceae

Rates of carbapenem-resistant Enterobacteriaceae (CRE), especially Klebsiella pneumoniae carbapenemase (KPC)-producing Gram-negatives, have increased worldwide. Infections caused by these organisms have been associated with a high mortality, which might be due in part to the limited availability of antibiotic options. Therefore, prevention of acquisition of these organisms is essential. This review summarizes published infection control interventions (bundles) that have been implemented for the control of outbreaks caused by KPC-producing organisms. A total of 15 bundles of interventions aimed at controlling CRE outbreaks are presented. The interventions included combinations of increased compliance with hand hygiene and contact precautions, environmental cleaning, early identification of asymptomatic carriers, and physical separation of CRE-positive patients and their staff. Three bundles had staggered implementation of interventions with their later phase involving a combination of rectal surveillance cultures for identification of asymptomatic CRE carriers, cohorting of CRE-positive patients, and cohorting of the staff caring for CRE carriers. All three staggered bundles successfully decreased their CRE acquisition rates after implementation of their later phases. Bundles combine multiple interventions targeting different levels of the transmission pathways and most include increased hand hygiene and contact precautions. However, bundles implemented in phases would seem to indicate that active surveillance cultures and the subsequent cohorting of patients and staff based on these results might be particularly beneficial for controlling horizontal transmission.

Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention

During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae that was not controlled by local measures. A nationwide intervention was launched to contain the outbreak and to introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals. In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized carriers of carbapenem-resistant Enterobacteriaceae (CRE) and dedicated staffing and appointed a professional task force charged with containment. The task force paid site visits at acute-care hospitals, evaluated infection-control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided daily feedback on performance to hospital directors, and intervened additionally when necessary. The initial intervention period was 1 April 2007-31 May 2008. The primary outcome measure was incidence of clinically diagnosed nosocomial CRE cases. By 31 March 2007, 1275 patients were affected in 27 hospitals (175 cases per 1 million population). Prior to the intervention, the monthly incidence of nosocomial CRE was 55.5 cases per 100,000 patient-days. With the intervention, the continuous increase in the incidence of CRE acquisition was halted, and by May 2008, the number of new monthly cases was reduced to 11.7 cases per 100,000 patient-days (P<.001). There was a direct correlation between compliance with isolation guidelines and success in containment of transmission (P=.02). Compliance neutralized the effect of carrier prevalence on new incidence (P=.03). A centrally coordinated intervention succeeded in containing a nationwide CRE outbreak after local measures failed. The intervention demonstrates the importance of strategic planning and national oversight in combating antimicrobial resistance.

Controlling the Spread of Carbapenemase-Producing Bacteria

Background: During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae, producing the serine carbapenemase KPC-3. Locally-implemented infection control measures in affected hospitals failed to contain spread. A nationwide intervention was launched to contain the outbreak and introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals. Methods: In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized carriers of carbapenem-resistant Enterobacteriaceae (CRE) and dedicated staffing, and appointed a professional task force charged with containing spread of the epidemic strain. The task force paid site visits at acute care hospitals, evaluated infection control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided regular feedback on performance to hospital directors, and intervened additionally when necessary. During 2008, the intervention was extended to long-term care facilities, and in June 2008 national guidelines for active surveillance were issued. The primary outcome measure was the incidence of clinically diagnosed nosocomial CRE cases in acute care hospitals. Results: By March 2007, over 1200 patients were affected in acute care hospitals. Prior to the intervention, the monthly incidence of noscomial CRE climbed steadily, peaking at over 180 cases. Crude 30-day mortality was > 30%. With the intervention, the continuous rise in incidence of CRE acquisition was halted, and at the end of the 14-month initial intervention period the number of new monthly cases was 46. Following the introduction of active surveillance guidelines, monthly incidence fell further, reaching a low of 24 as of October 2009. A direct correlation was observed between compliance with isolation guidelines and success in containment of in-hospital CRE transmission. Conclusions: A centrally-coordinated public health intervention has succeeded in containing a nationwide outbreak of CRE in Israeli hospitals after local measures failed. The intervention demonstrates the importance of strategic planning and national oversight in combating antimicrobial resistance. Abstracts for SupplementInternational Journal of Infectious DiseasesVol. 14Preview Full-Text PDF Open Archive