Prevention of Colonization and Infection by Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae in Long-term Acute-Care Hospitals

Hayden, Mary K; Lin, Michael; Lolans, Karen; Weiner, Shayna; Blom, Donald; Moore, Nicholas; Fogg, Louis; Henry, David B.; Lyles, Rosie D.; Thurlow, Caroline; Sikka, Monica K; Hines, David; Weinstein, Robert A.

doi:10.1093/cid/ciu1173

Cited by 165 publications

(192 citation statements)

References 30 publications

Supporting

Mentioning

182

Contrasting

Unclassified

Order By: Relevance

“…Hayden and colleagues demonstrated that the use of an infection prevention bundle that included chlorhexidine bathing and strict isolation practices in a high-CRE-burden LTACH was able to significantly reduce the rates of both new CRE acquisitions and bacteremia cases (13). Computer model estimates suggest that a coordinated regional response, compared to individual hospital actions, has the potential to reduce or even eliminate CRE transmission (10,11).…”

mentioning

confidence: 99%

Commentary: Continuing Challenges for the Clinical Laboratory for Detection of Carbapenem-Resistant Enterobacteriaceae

Humphries

McKinnell

2015

J Clin Microbiol

View full text Add to dashboard Cite

Over the last decade, carbapenem-resistant Enterobacteriaceae (CRE) have become an urgent threat to health in the United States and elsewhere in the world (1, 2). The Centers for Disease Control and Prevention (CDC) have reported a steady increase in the burden of disease from CRE, particularly, carbapenem-resistant Klebsiella pneumoniae, in the United States (3, 4). Surveillance data from Chicago showed that 30% of residents of long-termacute-care hospitals (LTACHs) and 3.3% of patients in hospital intensive care units (ICUs) were CRE carriers, suggesting that CRE infections are now endemic in parts of the United States (5). The spread of CRE in the U.S. health care system comes at a great cost because there are limited available treatment options and high attributable mortality from CRE (6, 7).Spread of CRE in the United States appears to be driven by movement of patients though the health care system (8, 9). For instance, the CDC epicenters program demonstrated that patient transfers led to regional spread of CRE across 26 health care facilities in four counties (8). The transfer of CRE-colonized patients not only moves these organisms between institutions but also accelerates the epidemic through subsequent patient transmission events at each institution as the incidence of CRE increases (10) (11). To this point, a study of New York hospitals found that the odds of a patient acquiring CRE increased by 15% for each 1% increase in overall patient colonization at the facility (12).Recent research has shown some promising findings for curbing the spread of CRE. Hayden and colleagues demonstrated that the use of an infection prevention bundle that included chlorhexidine bathing and strict isolation practices in a high-CRE-burden LTACH was able to significantly reduce the rates of both new CRE acquisitions and bacteremia cases (13). Computer model estimates suggest that a coordinated regional response, compared to individual hospital actions, has the potential to reduce or even eliminate CRE transmission (10, 11).Such interventions require an understanding of the prevalence of CRE at the institutional level. However, the true burden of CRE at the local, regional, or national level remains poorly understood. Our limited understanding of CRE burden is due in part to challenges faced by the clinical laboratory at identifying CRE-in both clinical and surveillance cultures. In 2010, the Clinical and Laboratory Standards Institute (CLSI) revised the carbapenem breakpoints for the Enterobacteriaceae, and the U.S. Food and Drug Administration (FDA) followed suit by revising the drug product labeling to include these revised breakpoints. However, no manufacturer of commercial automated antimicrobial susceptibility test (AST) systems has obtained FDA clearance for these new standards, despite over 5 years having passed since their approval. Almost all laboratories in the United States rely on these systems for routine AST, and few have the resources to conduct the studies required to establish the performance of these syste...

show abstract

mentioning

confidence: 99%

Commentary: Continuing Challenges for the Clinical Laboratory for Detection of Carbapenem-Resistant Enterobacteriaceae

Humphries

McKinnell

2015

J Clin Microbiol

View full text Add to dashboard Cite

show abstract

“…Early identification of patients colonized with carbapenemase-producing CRE (CP-CRE) and implementation of infection prevention strategies that include strict isolation practices have the potential to significantly slow the trajectory of CP-CRE dissemination in the United States (12)(13)(14). However, such interventions critically depend on accurate and rapid identification of patients colonized or infected by CRE through laboratory testing.…”

mentioning

confidence: 99%

Use of Ancillary Carbapenemase Tests To Improve Specificity of Phenotypic Definitions for Carbapenemase-Producing Enterobacteriaceae

2017

View full text Add to dashboard Cite

Carbapenemase-producing Enterobacteriaceae (CPE) are a significant threat to public health. In 2015, CDC revised the surveillance definition for CPE to include all Enterobacteriaceae resistant to any carbapenem tested. However, this definition is associated with poor specificity. We evaluated the performance of this definition, compared to carbapenemase PCR, for a collection of 125 Enterobacteriaceae. We also investigated the impact of ancillary testing for carbapenemase of isolates that met the CDC CPE surveillance definition. The two ancillary tests evaluated were the Xpert Carba-R assay, a molecular test, and the carbapenem inactivation method (CIM). Two variables were evaluated for the CIM: suspension of organisms in double-distilled water (ddH 2 O) versus tryptic soy broth (TSB) to incubate disks, and incubation of plates for 6 h versus 18 to 20 h. The sensitivity and specificity of the Carba-R assay were 100% compared to the results of in-house PCR. The sensitivities of the CIM performed with TSB were 94.6% when read at 6 h and 97.7% when read at 18 to 20 h; the sensitivities with ddH 2 O were 88.0% when read at 6 h and 93.0% when incubated for 18 to 20 h. The specificity was 100% for all variables tested. Without ancillary testing, the sensitivity of the CDC definition was 98.9% for CPE, and the specificity was 6.1%. Testing isolates that screened positive by the CDC definition with the Xpert Carba-R did not change the sensitivity, and it improved the specificity to 100%. Similarly, the use of the CIM (TSB and 18 to 20 h of incubation) to confirm screen-positive isolates resulted in a sensitivity of 95.6% and specificity of 100%.KEYWORDS Carba-R, Enterobacteriaceae, carbapenamase, carbapenem inactivation method C arbapenem-resistant Enterobacteriaceae (CRE), particularly those that are resistant due to carbapenemase production, are a significant threat to public health. Infections caused by CRE are associated with a high attributable mortality (1), and U.S. surveillance data have demonstrated a steady increase in the burden of disease caused by CRE since 2000 (2). The U.S. CRE epidemic is driven, in part, by Klebsiella pneumoniae isolates of sequence type (ST) 258 that express the K. pneumoniae carbapenemase (KPC) (3). Transfer of patients colonized or infected with this organism between health care institutions is thought to have led to the dissemination of ST 258 K. pneumoniae across the country. One particularly well documented outbreak described by the Centers for Disease Control and Prevention Epicenter Program demonstrated that patient transfers between 26 health care facilities across four counties lead to the spread of KPCproducing CRE to 40 patients over a 1-year period (4). Subsequent studies in this region documented that nearly 1 in 3 residents of long-term acute care facilities were colonized with KPC-producing CRE (5). CRE harboring other carbapenem-hydrolyzing enzymes, such as NDM, VIM, IMP, or the OXA-48 type, common in other areas of the world (6), are also spreading in the Unite...

show abstract

“…The key components of a successful hospital bundle for MDRGN are yet to be determined but have been successful at reducing nosocomial infection rates and controlling outbreaks. Most include improved hand hygiene compliance, contact precaution, control interventions cohort, staff education, and environmental disinfection [76][77][78][79][80] (Table 6). Other infection prevention strategies such as decolonization of patients by the use of daily chlorhexidine bathing have also demonstrated a reduction in the acquisition of MDR Gram-negative bacteria.…”

Section: Resultsmentioning

confidence: 99%

“…Other infection prevention strategies such as decolonization of patients by the use of daily chlorhexidine bathing have also demonstrated a reduction in the acquisition of MDR Gram-negative bacteria. 78 In addition, selective decontamination strategies have shown to be safe and possibly effective during therapy, but success at decolonization may favour the emergence of resistant strains and longterm effects are unclear. …”

Section: Resultsmentioning

confidence: 99%

Multidrug-resistant Gram-negative bacteria-resistant infections: epidemiology, clinical issues and therapeutic options

2016

View full text Add to dashboard Cite

IntroductionIn the last decade, we have witnessed a dramatic increase worldwide in the number of multidrug resistant Gram-negative (MDRGN) bacterial pathogens, with Enterobacteriacae (mostly Klebsiella pneumoniae), Pseudomonas aeruginosa and Acinetobacter baumannii being the major threats in clinical practice. Due to the resistance to the most common antibiotics prescribed as empiric regimens, MDRGN bugs have been associated with delays in an adequate treatment, leading to significant increases in morbidity and mortality.1 In addition, the spread of MDRGN pathogens resulted over last years in a vicious circle of an indiscriminate prescription of broad-spectrum antimicrobials and further resistance selection. 2The aim of this review is to describe the mechanism of resistance, epidemiology, risk factors, clinical issues, and therapeutic options of MDRGN pathogens. Mechanism of resistance of Gram-negative bacteriaMGRGN bacteria are defined as pathogens carrying resistance to one or more antimicrobials from at least three different classes. The most common mechanism of resistance is represented by intrinsic and acquired production of b-lactamases, which can be chromosomal or plasmid mediated. b-lactamases are hydrolytic enzymes able to disrupt the b-lactam ring, thus inactivating different classes of b-lactams.3,4 The most common enzymes in clinical practice are the extended-spectrum-b-lactamases (ESBLs), which are mostly expressed by Enterobacteriaceae. A novel type of class C b-lactamases also showing activity against cefepime and denominated extended spectrum AmpC b-lactamases has been described. 4 The consequent abuse of carbapenems, representing the first choice for ESBL infections, led to a progressive increase in carbapenem resistance, mainly due to the production of carbapenem-hydrolyzing b-lactamases, or carbapenemases, that usually confer clinical resistance to most b-lactams.5,6 K. pneumoniae carbapenemases (KPCs) are the most relevant enzymes among Enterobacteriaceae, and confer resistance to all the blactams, including b-lactam/b-lactamase inhibitors combinations. Class B enzymes, named metallo-b-lactamases are expressed by both enterics and P. aeruginosa and confer resistance to all b-lactams with the exception of aztreonam. Oxacillinases belong to the class D b-lactamases, and are mostly expressed in P. Multidrug-resistant Gram-negative bacteria-resistant infections: epidemiology, clinical issues and therapeutic optionsMatteo Bassetti, Davide Pecori, Maddalena Peghin Infectious Diseases Clinic, Santa Maria Misericordia University Hospital, Udine, Italy ABSTRACTIn the last decade, we have witnessed a dramatic increase in the number of multidrug resistant Gram-negative (MDRGN) bacterial pathogens, both in Italy and worldwide, with Enterobacteriacae (mostly Klebsiella pneumoniae), Pseudomonas aeruginosa and Acinetobacter baumannii being the major threats in clinical practice. Inadequate empirical antimicrobial therapy of severe infections caused by MDR Enterobacteriacae has been associated with an increa...

show abstract

Prevention of Colonization and Infection by Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae in Long-term Acute-Care Hospitals

Abstract: 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.

Cited by 165 publications

References 30 publications

Commentary: Continuing Challenges for the Clinical Laboratory for Detection of Carbapenem-Resistant Enterobacteriaceae

Commentary: Continuing Challenges for the Clinical Laboratory for Detection of Carbapenem-Resistant Enterobacteriaceae

Use of Ancillary Carbapenemase Tests To Improve Specificity of Phenotypic Definitions for Carbapenemase-Producing Enterobacteriaceae

Multidrug-resistant Gram-negative bacteria-resistant infections: epidemiology, clinical issues and therapeutic options

Contact Info

Product

Resources

About