Outbreak of Carbapenem-Resistant Enterobacteriaceae at a Long-Term Acute Care Hospital: Sustained Reductions in Transmission through Active Surveillance and Targeted Interventions
Objective. To describe a Klebsiella pneumoniae carbapenemase (KPC)-producing carbapenem-resistant Enterobacteriaceae (CRE) outbreak and interventions to prevent transmission. Design, setting, and patients. Epidemiologic investigation of a CRE outbreak among patients at a long-term acute care hospital (LTACH). Methods. Microbiology records at LTACH A from March 2009 through February 2011 were reviewed to identify CRE transmission cases and cases admitted with CRE. CRE bacteremia episodes were identified during March 2009-July 2011. Biweekly CRE prevalence surveys were conducted during July 2010-July 2011, and interventions to prevent transmission were implemented, including education and auditing of staff and isolation and cohorting of CRE patients with dedicated nursing staff and shared medical equipment. Trends were evaluated using weighted linear or Poisson regression. CRE transmission cases were included in a case-control study to evaluate risk factors for acquisition. A real-time polymerase chain reaction assay was used to detect the bla(KPC) gene, and pulsed-field gel electrophoresis was performed to assess the genetic relatedness of isolates. Results. Ninety-nine CRE transmission cases, 16 admission cases (from 7 acute care hospitals), and 29 CRE bacteremia episodes were identified. Significant reductions were observed in CRE prevalence (49% vs 8%), percentage of patients screened with newly detected CRE (44% vs 0%), and CRE bacteremia episodes (2.5 vs 0.0 per 1,000 patient-days). Cases were more likely to have received β-lactams, have diabetes, and require mechanical ventilation. All tested isolates were KPC-producing K. pneumoniae, and nearly all isolates were genetically related. Conclusion. CRE transmission can be reduced in LTACHs through surveillance testing and targeted interventions. Sustainable reductions within and across healthcare facilities may require a regional public health approach.
[Show abstract] [Hide abstract] ABSTRACT: . We conducted this case-control study to determine the risk factors and treatment outcome of infections due to carbapenem resistant Enterobacteriaceae in our institution. Methods . This is a matched case-control study of patients with infection due to carbapenem resistant Enterobacteriaceae (CRE) and carbapenem susceptible Enterobacteriaceae (CSE), from Riyadh, Saudi Arabia, between March 2012 and December 2013. Results . During this period, 29 cases and 58 controls were studied. The mean ages of the cases (55.4 years) and controls (54.7 years) were similar ( p = 0.065 ). Cases had higher mean Charlson comorbidity index (CCI) (3.1) than controls (1.9), p = 0.026 . Several factors contributed to infection among the studied population. Prior uses of piperacillin-tazobactam, a carbapenem, a quinolone, and metronidazole were significantly associated with CRE infections. Nine of the cases died compared with 7 of the controls, p = 0.031 . Mortality was associated with advanced age, the presence of comorbidities, ICU stay, and receipt of invasive procedures. Conclusions . Infections due to CRE resulted in a significantly increased mortality. Combination antibiotic therapy was associated with reduced mortality. Properly designed randomized controlled studies are required to better characterize these findings.0Comments 0Citations
- "Not being in the ICU is protective against CRE infection. These findings are in agreement with previous studies . Ho et al.  however reported no significant increase in the rate of carbapenem resistance among their patients during the period 2006 to 2010 despite a significant increase in consumption. Recent studies from Saudi Arabia  and other Gulf countries  showed that OXA-48 and NDM-1 are the dominant carbapenemases among Enterobacteriaceae with low prevalence of VIM. "
- "To cater the antibiotic resistance due to extended spectrum beta-lactamases (ESBLs), carbapenem drugs have been introduced in clinical settings. Although, carbapenem drugs play a vital role in the management of the infections caused by ESBLs producing organisms due to their broad spectrum activity and stability to hydrolysis against ESBLs , carbapenem resistance among the members of the Enterobacteriaceae, Pseudomonas and Acinetobacter has been reported globally [11,15,22,30]. The common mechanisms of carbapenem resistance are carbapenem hydrolyzing enzymes, changes in outer membrane proteins, over expression of efflux pumps . "
[Show abstract] [Hide abstract] ABSTRACT: Carbapenems are broad-spectrum β-lactam antimicrobials used for the treatment of serious infections in humans. To date only sporadic studies have reported the occurrence of carbapenemase-producing (CP) bacteria in food-producing animals and their environment. The bacteria and enzymes isolated include VIM-1 producing Escherichia coli and Salmonella Infantis from pigs and poultry in Germany, OXA-23-producing Acinetobacter spp. from cattle and horses in France and Belgium, and NDM-producing Acinetobacter spp. from pigs and poultry in China. In the German S. Infantis and E. coli isolates, the VIM-1-encoding genes were located on IncHI2 plasmids. A methodology including selective culture is proposed for the detection of CP strains of Enterobacteriaceae and Acinetobacter spp. The choice of selective media for the surveillance of carbapenem resistance for testing animal and food samples needs to be experimentally evaluated and validated. Biochemical and phenotypic tests for the confirmatory identification of CP bacteria are available. For CP bacteria in animals and food, active/passive monitoring and/or targeted surveys should cover key zoonotic agents, animal pathogens and indicator organisms. Priority should be given to broilers, fattening turkeys, fattening pigs, veal calves and meat thereof. Because there are no data on the comparative efficacy of individual control options, prioritisation is complex. Continued prohibition of the use of carbapenems in food-producing animals would be a simple and effective option. As genes encoding carbapenemase production are mostly plasmid-mediated, and co-resistance may be an important issue in the spread of such resistance mechanisms, decreasing the frequency of use of antimicrobials in animal production in the EU in accordance with prudent use guidelines is also of high priority. The effectiveness of any control measures should be monitored by targeted surveys, using selective isolation methods and pre-enrichment of samples. Control measures should be proactively implemented at national and international levels to prevent CP strains become widespread in livestock.0Comments 0Citations
- "This secondary transmission can quickly lead to outbreaks, epidemics and, if left unchecked, to endemicity (Grundmann et al., 2010; Nordmann et al., 2011a). Lastly, studies performed for CPE and CNSE have shown that infection or colonization has been associated with in-hospital mortality rates of 40-50% (Patel et al., 2008; Gasink et al., 2009; Marchaim et al., 2010; Chitnis et al., 2012). The risk posed by infections with these MDR microorganisms becomes even greater when considering the very limited number of new antimicrobial agents that are in the developmental pipeline (Boucher et al., 2009; ECDC and EMEA, 2009; Livermore et al., 2011). "