ReviewPriorities in the prevention and control of multidrug-resistant Enterobacteriaceae in hospitals
Introduction
Recent years have seen greater emphasis in the UK and elsewhere on preventing and controlling healthcare-associated infection (HCAI), resulting in a decline in one of the more serious manifestations, i.e. bloodstream infection (BSI) due to meticillin-resistant Staphylococcus aureus (MRSA). Bloodstream infection due to Escherichia coli and other Enterobacteriaceae has become more prevalent, along with increasing antibiotic resistance. Traditionally, beta-lactam antibiotics have been used in the management of BSI and other infections caused by Enterobacteriaceae, but more strains currently demonstrate the presence of extended-spectrum beta-lactamases (ESBLs) which confer resistance to penicillins as well as to most cephalosporins, except the cephamycins. The genes responsible for the production of these enzymes among Enterobacteriaceae are often accompanied by resistance to other groups of antibiotics, e.g. aminoglycosides and fluoroquinolones. The emergence of carbapenem-resistant Enterobacteriaceae (CRE) has been described in a number of countries and there are limited options for treatment of infections caused by these organisms, hence the importance of infection prevention and control measures.
The origins and subsequent dissemination of ESBLs have been highlighted.1, 2 The classification of ESBLs is complex and beyond the scope of this review. Many enzymes are responsible, the most prevalent being CTX-M. Whereas CREs are a more recent phenomenon, their evolution and spread indicate a complex and sophisticated genetic evolution involving transcontinental spread.3, 4, 5 Paterson and Doi in 2007 likened the emergence of these bacteria to Mycobacterium tuberculosis, which also demonstrates multidrug and extreme drug resistance.6 The definition of pan-resistance among Gram-negative bacilli is complicated by susceptibility testing and whether carried out according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) or Clinical and Laboratory Standards Institute (CLSI) methods.6 More recently, definitions for multi-, extensively and pandrug-resistant bacteria have been proposed, the last of these implying resistance to all antibiotic classes available for empirical treatment.7
Acquisition of drug-resistant Gram-negative bacilli is usually associated with admission to a tertiary hospital, but both ESBLs and CREs can be found outside acute hospitals such as patient carriage in long-term care facilities.8, 9, 10 Multidrug-resistant Enterobacteriaceae (MDE) can be detected in the hospital environment, including in discharge waste from hospitals and also in animal reservoirs.11, 12, 13, 14, 15 Since the road between the community and the hospital runs both ways, patients can carry these bacteria into hospital and return them to the community from the hospital.
While Acinetobacter spp. survive in surface dust for months, bacteria such as E. coli, Klebsiella spp., Enterobacter spp. and Serratia spp., have not generally demonstrated enhanced resilience to desiccation. It is generally assumed that Gram-negative micro-organisms require moist or damp sites for enhanced longevity.16 Recent reports suggest that E. coli and Klebsiella spp. may survive more than a year in dry surroundings, however, and Serratia marcescens for up to two months.16 Therefore the healthcare environment could be an important reservoir for Gram-negative bacteria during outbreaks, given their proven ability to survive on surfaces.16, 17, 18, 19
A study performed in 1989 found enterobacter on patient charts, and more recently, another demonstrated that 5% of about 2000 environmental sites were positive for E. coli, enterobacter, serratia and klebsiella, e.g. bedside tables, chairs, floors, door handles and infusion pumps, and as expected from bathroom sites such as urinals, shower fittings, sinks and toilet seats.20, 21, 22 These environmental coliforms were indistinguishable from those from the patient whose environment was sampled.21 Another study suggests that multidrug-resistant klebsiella is more likely to contaminate the immediate environment of colonized or infected patients than E. coli.23 Coliforms recovered from the healthcare environment display antibiotic resistance profiles that reflect local prescribing practices; indeed, wards or units that are constantly exposed to antibiotics are more likely to harbour resistant micro-organisms.22 Despite terminal cleaning, prior room occupancy has been shown to be a risk for the acquisition of some Gram-negative micro-organisms in the intensive or critical care setting.24, 25 This finding, along with similar reports for MRSA, vancomycin-resistant enterococci (VRE) and Clostridium difficile, probably offers the best available evidence for the role of the environment in HCAI.26
Traditional sites for Gram-negative microbes in hospitals have been those constantly or intermittently exposed to water. This includes hand-wash basins, sinks, sluices, showers, baths and toilets. Bacterial biofilm builds up in plumbing components, including taps, water filters and sink traps underneath water outlets. It hosts and protects a multitude of water-loving organisms and poses a threat to nearby debilitated patients.27 In addition, bacteria within biofilm may display greater capacity for antimicrobial resistance, and tolerate chlorine and other disinfectants.28 Biofilm-forming Klebsiella pneumoniae have also been shown to be more likely to produce extended-spectrum beta-lactamases.29, 30 A recent study utilizing electron microscopy of common hospital sites has reported the presence of biofilm capable of offering protection for a range of multidrug-resistant bacteria on dry surfaces.29
The risk factors associated with the acquisition of ESBLs and CREs include underlying malignancy, patients requiring multiple interventions or antibiotics, and the occurrence of more than one genotype.31, 32, 33, 34, 35, 36 The international spread of these bacteria and their presence in the food chain, as recently described in Nottingham, UK, implies that their prevention and control is a greater challenge than that presented by MRSA and C. difficile.37
This review outlines priorities for the prevention and control of MDE, in acute hospitals within the limitations of current literature. Areas requiring further evaluation and research are also highlighted.
Section snippets
Screening and laboratory detection
Unlike MRSA and VRE, there is less agreement about who and when to screen and which identification methods to use for MDE, due to the diversity of bacteria involved and their resistance mechanisms. Most of what follows is summarized from descriptive data and outbreak reports rather than from well-conducted studies although the US Centers for Disease Control and Prevention have issued a guidance document on CRE and a group of European experts has surveyed existing knowledge on therapeutic and
Conclusions and future needs
Currently the scientific literature is vague on optimal practice for many aspects of the prevention and control of MDE and official guidelines are much needed given the major public health threat that MDE represent and the many challenges that infection prevention and control practitioners and others face on a daily basis. A recent report from a 535-bed Israeli hospital with endemic carbapenem-resistant K. pneumoniae suggests that success is possible as the incidence of cases and the
Conflict of interest statement
H.H. has had recent research collaborations with Steris Corporation, Inov8 Science, Pfizer and Cepheid. He has also recently received lecture and other fees from Novartis, AstraZeneca and Astellas. S.D. has received non-recurring lectureship fees and conference support from Pfizer, Novartis and Janssen-Cilag. A.S.K. has no conflicts of interest.
Funding sources
None.
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Frequency of surface bacterial contamination in family physicians’ offices
2021, Infectious Diseases NowCitation Excerpt :It has long been assumed that Gram-negative bacteria survival time on surfaces was short. Recent studies [22,23] challenged this hypothesis, and there is growing consensus that environmental cleanness could be as important for controlling transmission of multidrug-resistant E. coli as for MRSA and other organisms. A recent study conducted in France analyzed the near-patient environment bedside and reported that approximately 25% of the sites tested were contaminated, presumably by the patient's own bacteria [24].
Staphylococcus aureus resists UVA at low irradiance but succumbs in the presence of TiO <inf>2</inf> photocatalytic coatings
2019, Journal of Photochemistry and Photobiology B: BiologyCitation Excerpt :Surface recontamination rates following cleaning are rapid [3]. Other methods of environmental surface decontamination include use of steam, hydrogen peroxide vapour, ozone and UV light [4]. However, the effectiveness of these methods is limited because uniform dispersal of the active agent in a 3-dimensional space is rarely achieved.
Carbapenem-resistant Enterobacteriaceae at a low prevalence tertiary care center: Patient-level risk factors and implications for an infection prevention strategy
2017, American Journal of Infection ControlCitation Excerpt :Little evidence of transmission was found within a sizeable dataset; however, the studies concluded CRE spread was likely occurring unseen. Active screening has been suggested as a necessary control measure for CRE.6-8 In our center, PPT and clinical culture prevalence suggest that active screening for CRE detection would be low yield.
Current outcomes and predictors of treatment failure in patients with surgical site infection after elective colorectal surgery. A multicentre prospective cohort study
2017, Journal of InfectionCitation Excerpt :Preoperative chemoradiotherapy and poor compliance with an enhanced recovery program are also associated with higher readmission rates.13 Furthermore, the emergence of multidrug-resistance, particularly extended-spectrum β-lactamase (ESBL) and carbapenemase production among Gram-negative bacilli (GNB) is a matter of particular concern14,15 and may negatively impact treatment response in SSI. At present, data regarding predictors of treatment failure or mortality in patients with SSI after colorectal surgery remain limited.
Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors
2015, Journal of Hospital InfectionCitation Excerpt :Multiple drug-resistant organisms (MDROs) such as vancomycin-resistant enterococci (VRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Enterobacteriaceae (CRE) and meticillin-resistant Staphylococcus aureus (MRSA) can survive in the hospital environment for a prolonged period and are major players in causing hospital outbreaks, thus requiring infection control attention.1–7 Therefore, besides the implementation of active surveillance culture, practice of contact precautions, and of promotion of hand hygiene with alcohol-based hand rub, environmental hygiene is another critical control point in infection control.8,9 Unlike practising hand hygiene after direct contact with patients' bodies, hand hygiene after contact with patients' surroundings is often forgotten and missed by healthcare workers (HCWs) and visitors.10,11
Patients transferred from another hospital: source of infection of multiresistant microorganisms. results of six years of active surveillance program
2014, Revista Medica Clinica Las Condes