Emergence and Rapid Regional Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae
ABSTRACT Background. Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae are an emerging antibiotic resistance threat with demonstrated epidemic potential. Methods. We conducted an outbreak investigation of KPC-producing Enterobacteriaceae among patients of acute and long-term acute care hospitals (LTACHs) in 4 adjacent counties in Indiana and Illinois from 1 January 2008 through 31 December 2008 (cases). The study used traditional and molecular epidemiologic methods and an adaptation of social network analysis ("exposure network analysis"). Results. Clinical records for 40 (95%) of 42 patients were available. Patients were mostly older with multiple comorbid conditions. Eleven patients (27.5%) died during the index hospitalization or were discharged to hospice; 23 (57.5%) were discharged to a nursing home, and 4 (10.0%) were discharged to home. One LTACH (LTACH-A) was central to the regional outbreak: 24 (60%) of 40 cases were linked to LTACH-A, and at least 10 patients (25%) acquired KPC there. Of 16 cases not linked to LTACH-A, 12 (75%) were linked to 3 nursing homes. Only 4 patients (10%) definitely acquired KPC during an acute care hospital stay. Molecular typing revealed the 31 available KPC-positive K. pneumoniae isolates to be similar and to cluster with epidemic multilocus sequence type 258; 2 KPC-positive Escherichia coli isolates were unique. Conclusions. We observed extensive transfer of KPC-positive patients throughout the exposure network of 14 acute care hospitals, 2 LTACHs, and 10 nursing homes. Although few cases were identified at most institutions, many facilities were affected. Successful control of KPC-producing Enterobacteriaceae will require a coordinated, regional effort among acute and long-term health care facilities and public health departments.
SourceAvailable from: Nicholas M. Moore[Show abstract] [Hide abstract]
ABSTRACT: Background. Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) are an increasing threat to healthcare institutions. Long-term acute care hospitals (LTACHs) have especially high prevalence of KPC. Methods. Using a stepped-wedge design, we tested whether a bundled intervention (screening patients for KPC rectal colonization upon admission and every other week; contact isolation and geographic separation of KPC-positive patients in ward cohorts or single rooms; bathing all patients daily with chlorhexidine gluconate; and healthcare worker education and adherence monitoring) would reduce colonization and infection due to KPC in four LTACHs with high endemic KPC prevalence. The study was conducted between February 1, 2010-June 30, 2013; 3,894 patients were enrolled during pre-intervention (16-29 months) and 2,951 patients were enrolled during intervention (12-19 months). KPC colonization prevalence was stable during pre-intervention (average, 45.8%; 95% CI 42.1-49.5%), declined early during intervention, then reached a plateau (34.3%; 95% CI 32.4%-36.2%; p<0.001 for exponential decline). During intervention, KPC admission prevalence remained high (average, 20.6%, 95% CI 19.1%-22.3%). The incidence-rate of KPC colonization fell during intervention from 4 to 2 acquisitions/100 patient-weeks (p=0.004 for linear decline). Compared to pre-intervention, average rates of clinical outcomes declined during intervention: KPC in any clinical culture (3.7 to 2.5/1000 patient-days, p=0.001), KPC bacteremia (0.9 to 0.4/1000 patient-days, p=0.008), all-cause bacteremia (11.2 to 7.6/1000 patient-days, p=0.006) and blood culture contamination (4.9 to 2.3/1000 patient-days, p=0.03). A bundled intervention was associated with clinically important and statistically significant reductions in KPC colonization, KPC infection, all-cause bacteremia and blood culture contamination in a high-risk LTACH population. © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: firstname.lastname@example.org.Clinical Infectious Diseases 12/2014; DOI:10.1093/cid/ciu1173 · 9.42 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: 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.JAMA The Journal of the American Medical Association 10/2014; 312(14):1447-1455. DOI:10.1001/jama.2014.12720 · 30.39 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: In the absence of clinical resistance, breakpoints for many antimicrobial agents are often set high. Clinical failures following use of the agents over time requires re-evaluation of breakpoints. This is based on patient response, pharmacokinetic/pharmacodynamic information and in vitro minimal inhibitory concentration data. Data from the SENTRY Antimicrobial Surveillance Program has shown that Clinical and Laboratory Standards Institute breakpoint changes for carbapenems that occurred between 2008 and 2012 in North America have resulted in decreased levels of susceptibility for some species. In particular, reduced susceptibility to imipenem was observed for Proteus mirabilis (35%) and Morganella morganii (80%). Minor decreases in susceptibility were also noted for Enterobacter species with ertapenem (5%) and imipenem (4.3%), and Serratia species with imipenem (6.4%). No significant decreases in susceptibility were observed for meropenem following the breakpoint changes. There were no earlier breakpoints established for doripenem. Very few of these Enterobacteriaceae produce carbapenamase enzymes; therefore, the clinical significance of these changes has not yet been clearly determined. In conclusion, ongoing surveillance studies with in vitro minimum inhibitory concentration data are essential in predicting the need for breakpoint changes and in identifying the impact of such changes on the percent susceptibility of different species.