Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Puerto Rico Associated with a Novel Carbapenemase Variant

2010 ◽  
Vol 31 (05) ◽  
pp. 476-484 ◽  
Author(s):  
Christopher J. Gregory ◽  
Eloisa Llata ◽  
Nicholas Stine ◽  
Carolyn Gould ◽  
Luis Manuel Santiago ◽  
...  
Keyword(s):  
Risk Factors ◽  
Puerto Rico ◽  
Klebsiella Pneumoniae ◽  
Antimicrobial Agents ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Control Measures ◽  
Control Group ◽  
Surveillance Culture ◽  
Carbapenem Resistant

Background.Carbapenem-resistantKlebsiella pneumoniae(CRKP) is resistant to almost all antimicrobial agents, and CRKP infections are associated with substantial morbidity and mortality.Objective.To describe an outbreak of CRKP in Puerto Rico, determine risk factors for CRKP acquisition, and detail the successful measures taken to control the outbreak.Design.Two case-control studies.Setting.A 328-bed tertiary care teaching hospital.Patients.Twenty-six CRKP case patients identified during the outbreak period of February through September 2008, 26 randomly selected uninfected control patients, and 26 randomly selected control patients with carbapenem-susceptibleK. pneumoniae(CSKP) hospitalized during the same period.Methods.We performed active case finding, including retrospective review of the hospital's microbiology database and prospective perirectal surveillance culture sampling in high-risk units. Case patients were compared with each control group while controlling for time at risk. We sequenced theblaKPCgene with polymerase chain reaction for 7 outbreak isolates and subtyped these isolates with pulsed-field gel electrophoresis.Results.In matched, multivariable analysis, the presence of wounds (hazard ratio, 19.0 [95% confidence interval {CI}, 2.5-142.0]) was associated with CRKP compared with noK. pneumoniae.Transfer between units (adjusted odds ratio [OR], 7.5 [95% CI, 1.8-31.1]), surgery (adjusted OR, 4.0 [95% CI, 1.0-15.7]), and wounds (adjusted OR, 4.9 [95% CI, 1.1-21.8]) were independent risk factors for CRKP compared to CSKP. A novelK. pneumoniaecarbapenemase variant (KPC-8) was present in 5 isolates. Implementation of active surveillance for CRKP colonization and cohorting of CRKP patients rapidly controlled the outbreak.Conclusions.Enhanced surveillance for CRKP colonization and intensified infection control measures that include limiting the physical distribution of patients can reduce CRKP transmission during an outbreak.

scholarly journals Derivation of a Model to Guide Empiric Therapy for Carbapenem-Resistant Klebsiella pneumoniae Bloodstream Infection in an Endemic Area

2020 ◽  
Vol 7 (7) ◽  
Author(s):  
Gregory Weston ◽  
Fathima Jahufar ◽  
Nikhil Sharma ◽  
Christopher Su ◽  
Eran Bellin ◽  
...  
Keyword(s):  
Blood Culture ◽  
Klebsiella Pneumoniae ◽  
Bloodstream Infection ◽  
Tertiary Care ◽  
Classification Rule ◽  
Control Group ◽  
Care Hospital ◽  
Clinical Classification ◽  
Carbapenem Resistant ◽  
Good Ability

Abstract Background Appropriate therapy for carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infection (BSI) is often given late in the course of infection, and strategies for identifying CRKP BSI earlier are needed. Methods A retrospective case–control study was performed at a tertiary care hospital, university hospital, and community hospital in Bronx, New York. All participants had a blood culture sent and received an antibiotic within 48 hours of the culture. The case group (n = 163) had a blood culture with CRKP. The control group (n = 178) had a blood culture with carbapenem-susceptible Klebsiella. Data were obtained by electronic or conventional medical record abstraction. A multiple logistic regression model was built to identify associated factors and develop a clinical model for CRKP BSI. Model performance characteristics were estimated using a 10-fold cross-validation analysis. Results A prior nonblood culture with carbapenem-resistant Enterobacteriaceae, skilled nursing facility (SNF) residence, mechanical ventilation, and admission >3 days were strongly associated risk factors. A significant interaction led to development of separate clinical models for subjects admitted <3 days at the time of positive blood culture from those admitted at least 3 days. The derived models had a good ability to discriminate between subjects with and without CRKP BSI. A clinical classification rule to guide therapy can prioritize sensitivity or specificity. Conclusions Prior nonblood cultures showing resistance and exposure to SNF and health care settings are factors associated with carbapenem resistance. The clinical classification rules derived in this work should be validated for ability to guide therapy.

Institutional Control Measures to Curtail the Epidemic Spread of Carbapenem-Resistant Klebsiella pneumoniae: A 4-Year Perspective

2011 ◽  
Vol 32 (7) ◽  
pp. 673-678 ◽  
Author(s):  
Matan J. Cohen ◽  
Colin Block ◽  
Phillip D. Levin ◽  
Carmela Schwartz ◽  
Ilana Gross ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Active Surveillance ◽  
Tertiary Care ◽  
Control Measures ◽  
Change Point Analysis ◽  
Carrier Status ◽  
Epidemic Spread ◽  
Carbapenem Resistant ◽  
Tertiary Care Medical Center ◽  
The Mean

Objective.To describe the implementation of an institution-wide, multiple-step intervention to curtail the epidemic spread of carbapenem-resistant Klebsiella pneumoniae (CRKP).Design.Consecutive intervention analyses.Patients and Setting.All patients admitted to a 775-bed tertiary care medical center in Jerusalem, Israel, from 2006 through 2010.Interventions.The effects of 4 interventions were assessed: (1) a policy of isolation for patients colonized or infected with CRKP in single rooms, which was started in March 2006; (2) cohorting of CRKP patients with dedicated nursing staff and screening of patients neighboring a patient newly identified as a carrier of CRKP, which was started in March 2007; (3) weekly active surveillance of intensive care unit patients, which was started during August 2008; and (4) selective surveillance of patients admitted to the emergency department, which was started in March 2009. Interrupted regression analysis and change-point analysis were used to assess the effect of each intervention on the CRKP epidemic.Results.Patient isolation alone failed to control the spread of CRKP, with incidence increasing to a peak of 30 new cases per 1,000 hospital beds per month. Institution of patient cohorting led to a steep decline in the incidence of CRKP acquisition (P< .001). Introduction of active surveillance interventions was followed by a decrease in the incidence of CRKP-positive clinical cultures but an increase in the incidence of CRKP-positive screening cultures. The mean prevalence of CRKP positivity for the period after cohorting began showed a statistically significant change from the mean prevalence in the preceding period (P< .001).Conclusions.The cohorting of patients with dedicated staff, combined with implementation of focused active surveillance, effectively terminated the epidemic spread of CRKP. Cohorting reduced cross-infection within the hospital, and active surveillance allowed for earlier detection of carrier status. Both interventions should be considered in attempts to contain a hospital epidemic.

scholarly journals A retrospective study of risk factors for carbapenem-resistant Klebsiella pneumoniae acquisition among ICU patients

2016 ◽  
Vol 10 (03) ◽  
pp. 208-213 ◽  
Author(s):  
Yangmin Hu ◽  
Yanting Ping ◽  
Leiqing Li ◽  
Huimin Xu ◽  
Xiaofeng Yan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Klebsiella Pneumoniae ◽  
Independent Risk Factor ◽  
Tertiary Care ◽  
Antibiotic Use ◽  
Clinical Factor ◽  
Icu Patients ◽  
Carbapenem Resistant ◽  
Bivariable Analysis

Introduction: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is rapidly emerging as a life-threatening nosocomial infection. In this study, we aim to identify risk factors, especially antibiotic use, for CRKP infection among intensive care unit (ICU) patients. Methodology: This was a matched case-control study of a 67-bed ICU in a tertiary care teaching hospital from 1 January 2011 through 30 June 2013. The control cases were selected among the patients with carbapenem-susceptible Klebsiella pneumoniae (CSKP) and were matched with CRKP cases for year of ICU admission and site of infection. The clinical outcomes and antibiotic treatments were analyzed. Results: One hundred and thirty patients were included in the study (65 cases and 65 controls). Bivariable analysis showed that age of patients (p = 0.044), number of antibiotic groups (p = 0.001), and exposure to carbapenems (p < 0.001) were associated with CRKP infection. Using multivariate analysis adjusted for age, prior hospitalization, number of antibiotic groups, and previous exposure to carbapenems, previous carbapenem exposure (p < 0.001) was identified as an independent risk factor for CRKP infection. Conclusions: These data suggest that exposure to carbapenems is an independent risk factor for CRKP infection. Patients with this clinical factor should be targeted for interventions to reduce the subsequent risk of infection.

scholarly journals Risk factors for infection with carbapenem-resistant Klebsiella pneumoniae: a case-case-control study

2014 ◽  
pp. 54-60 ◽  
Author(s):  
Viviana Gómez Rueda ◽  
John Jairo Zuleta Tobón
Keyword(s):  
Risk Factors ◽  
Klebsiella Pneumoniae ◽  
Case Control Study ◽  
Conditional Logistic Regression ◽  
Tertiary Care ◽  
Case Control ◽  
Carbapenem Resistant ◽  
Group I ◽  
Tertiary Care Institution ◽  
Control Study

Objetive: To evaluate the association between quinolone exposure and the emergence of carbapenem-resistant Klebsiella pneumoniae (CRKP) and to estimate CRKP-specific mortality. Methods: Case-case-control study implemented in a tertiary care institution. Three groups of patients were analyzed: 61 consecutive cases of infection with CRKP (Group I); 61 randomly chosen cases of patients infected with carbapenem-sensitive Klebsiella pneumoniae (CSKP; Group II); and 122 randomly chosen controls without CRKP or CSKP infection. Matching was based on the length of stay in intensive care unit and the date of bacterial isolation. An active search was performed for patients with CRKP and CSKP infection, and prospective cases were included in the study. We compared the results for Groups I and II against those for the controls by using two conditional logistic regression analyses that included infection as the dependent variable and controlled for time at risk and co-morbidities. Results: Exposure to quinolones was not associated with CRKP infection: no association was found in the analysis of CRKP with the controls (OR= 1.7; 95% CI: 0.2-6.5) or in the analysis of CSKP against the controls (OR= 0.6; 95% CI: 0.2-1.6). Use of carbapenems (OR = 3.3; 95% CI: 1.2-9.3) and colonization with CRKP (OR = 3.3; 95% IC: 1.2-9.3) were specific risk factors for infection with CRKP. Mortality associated with CRKP was 61.3%. Conclusion: No association was found between exposure to quinolones and infection with CRKP; however, colonization by CRKP and use of carbapenems are risk factors for infection with CRKP.

Nosocomial Transmission of New Delhi Metallo-β-Lactamase-1-Producing Klebsiella pneumoniae in Toronto, Canada

2013 ◽  
Vol 34 (1) ◽  
pp. 49-55 ◽  
Author(s):  
Christopher F. Lowe ◽  
Julianne V. Kus ◽  
Natasha Salt ◽  
Sandra Callery ◽  
Lisa Louie ◽  
...  
Keyword(s):  
Risk Factors ◽  
Klebsiella Pneumoniae ◽  
Care Center ◽  
Cohort Analysis ◽  
Tertiary Care ◽  
Control Measures ◽  
Nosocomial Transmission ◽  
Infection Prevention And Control ◽  
New Delhi ◽  
Retrospective Case

Design.An analysis of a cluster of New Delhi metallo-β-lactamase-l-producing Klebsiella pneumoniae (NDMl-Kp) and a retrospective case-cohort analysis of risk factors for acquisition in contacts of NDM1-Kp-positive patients.Setting.A 1,100-bed Canadian academic tertiary care center.Patients.Two index patients positive for NDMl-Kp as well as 45 contacts (roommates, ward mates, or environmental contacts) were investigated.Methods.Retrospective chart reviews of all patients colonized or infected with NDM1-Kp as well as contacts of these patients were performed in order to describe the epidemiology and impact of infection prevention and control measures. A case-cohort analysis was conducted investigating 45 contacts of NDM1-Kp-positive patients to determine risk factors for acquisition of NDM1-Kp. Rectal swabs were screened for NDMl-Kp using chromogenic agar. Presence of blaNDM-1 was confirmed by multiplex polymerase chain reaction. Clonality was assessed with pulsed-field gel electrophoresis (PFGE) using restriction enzyme XbaI.Results.Two index cases carrying NDM1-Kp with different PFGE patterns were identified. Nosocomial transmission to 7 patients (4 roommates, 2 ward mates, and 1 environmental contact) was subsequenüy identified. Risk factors for acquisition of NDM1-Kp were a history of prior receipt of certain antibiotics (fluoroquinolones [odds ratio (OR), 16.8 (95% confidence interval [CI], 1.30-58.8); P = .005], trimethoprim-sulfamethoxazole [OR, 11.3 (95% CI, 1.84-70.0); P = .01], and carbapenems [OR, 16.8 (95% CI, 1.79-157.3); P = .04]) and duration of exposure to NDM1-Kp-positive roommates (26.5 vs 6.7 days; P< .001).Conclusion.Two distinct clones of NDM1-Kp were transmitted to 7 inpatient contacts over several months. Implementation of contact precautions, screening of contacts for NDM1-Kp carriage, and attention to environmental disinfection contributed to the interruption of subsequent spread of the organism. The appropriate duration and frequency of screening contacts of NDMl-Kp-positive patients require further study.

A Randomized, Double-Blind, Placebo-Controlled Trial of Selective Digestive Decontamination Using Oral Gentamicin and Oral Polymyxin E for Eradication of Carbapenem-Resistant Klebsiella pneumoniae Carriage

2012 ◽  
Vol 33 (1) ◽  
pp. 14-19 ◽  
Author(s):  
Lisa Saidel-Odes ◽  
Hana Polachek ◽  
Nehama Peled ◽  
Klaris Riesenberg ◽  
Francisc Schlaeffer ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Controlled Trial ◽  
Tertiary Care ◽  
Selective Digestive Decontamination ◽  
Control Measures ◽  
University Hospital ◽  
Double Blind ◽  
Double Blind Placebo ◽  
Carbapenem Resistant ◽  
Polymyxin E

Objective.To assess the effectiveness of selective digestive decontamination (SDD) for eradicating carbapenem-resistant Klebsiella pneumoniae (CRKP) oropharyngeal and gastrointestinal carriage.Design.A randomized, double-blind, placebo-controlled trial with 7 weeks of follow-up per patient.Setting.A 1,000-bed tertiary-care university hospital.Patients.Adults with CRKP-positive rectal swab cultures.Methods.Patients were blindly randomized (1:1) over a 20-month period. The SDD arm received oral gentamicin and polymyxin E gel (0.5 g 4 times per day) and oral solutions of gentamicin (80 mg 4 times per day) and polymyxin E (1 × 106 units 4 times per day for 7 days). The placebo arm received oral placebo gel 4 times per day and 2 placebo oral solutions 4 times per day for 7 days. Strict contact precautions were applied. Samples obtained from the throat, groin, and urine were also cultured.Results.Forty patients (mean age ± standard deviation, 71 ± 16 years; 65% male) were included. At screening, greater than or equal to 30% of oropharyngeal, greater than or equal to 60% of skin, and greater than or equal to 35% of urine cultures yielded CRKP isolates. All throat cultures became negative in the SDD arm after 3 days (P< .0001). The percentages of rectal cultures that were positive for CRKP were significandy reduced at 2 weeks. At that time, 16.1% of rectal cultures in the placebo arm and 61.1% in the SDD arm were negative (odds ratio, 0.13; 95% confidence interval, 0.02–0.74; P<.0016). A difference between the percentages in the 2 arms was still maintained at 6 weeks (33.3% vs 58.5%). Groin colonization prevalence did not change in either arm, and the prevalence of urine colonization increased in the placebo arm.Conclusions.This SDD regimen could be a suitable decolonization therapy for selected patients colonized with CRKP, such as transplant recipients or immunocompromised patients pending chemotherapy and patients who require major intestinal or oropharyngeal surgery. Moreover, in outbreaks caused by CRKP infections that are uncontrolled by routine infection control measures, SDD could provide additional infection containment.Infect Control Hosp Epidemiol 2012;33(1):14-19

Potential Role of Active Surveillance in the Control of a Hospital-Wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae Infection

2010 ◽  
Vol 31 (6) ◽  
pp. 620-626 ◽  
Author(s):  
Debby Ben-David ◽  
Yasmin Maor ◽  
Nathan Keller ◽  
Gili Regev-Yochay ◽  
Ilana Tal ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Active Surveillance ◽  
Medical Center ◽  
Tertiary Care ◽  
Carbapenem Resistance ◽  
Control Measures ◽  
Interrupted Time Series Analysis ◽  
Contact Precautions ◽  
Carbapenem Resistant ◽  
Recent Emergence

Background.The recent emergence of carbapenem resistance among Enterobacteriaceae is a major threat for hospitalized patients, and effective strategies are needed.Objective.To assess the effect of an intensified intervention, which included active surveillance, on the incidence of infection with carbapenem-resistant Klebsiella pneumoniae.Setting.Sheba Medical Center, a 1,600-bed tertiary care teaching hospital in Tel Hashomer, Israel.Design.Quasi-experimental study.Methods.The medical records of all the patients who acquired a carbapenem-resistant K. pneumoniae infection during 2006 were reviewed. An intensified intervention was initiated in May 2007. In addition to contact precautions, active surveillance was initiated in high-risk units. The incidence of clinical carbapenem-resistant K. pneumoniae infection over time was measured, and interrupted time-series analysis was performed.Results.The incidence of clinical carbapenem-resistant K. pneumoniae infection increased 6.42-fold from the first quarter of 2006 up to the initiation of the intervention. In 2006, of the 120 patients whose clinical microbiologic culture results were positive for carbapenem-resistant K. pneumoniae, 67 (56%) developed a nosocomial infection. During the intervention period, the rate of carbapenem-resistant K. pneumoniae rectal colonization was 9%. Of the 390 patients with carbapenem-resistant K. pneumoniae colonization or infection, 204 (52%) were identified by screening cultures. There were a total of 12,391 days of contact precautions, and of these, 4,713 (38%) were added as a result of active surveillance. After initiation of infection control measures, we observed a significant decrease in the incidence of carbapenem-resistant K. pneumoniae infection.Conclusions.The use of active surveillance and contact precautions, as part of a multifactorial intervention, may be an effective strategy to decrease rates of nosocomial transmission of carbapenem-resistant K. pneumoniae colonization or infection.

scholarly journals Risk Factors for Gastrointestinal Colonization and Acquisition of Carbapenem-Resistant Gram-Negative Bacteria among Patients in Intensive Care Units in Thailand

2018 ◽  
Vol 62 (8) ◽  
Author(s):  
Anong Kiddee ◽  
Kanit Assawatheptawee ◽  
Anamai Na-udom ◽  
Pornpit Treebupachatsakul ◽  
Apirath Wangteeraprasert ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care ◽  
Intensive Care Units ◽  
Tertiary Care ◽  
Control Measures ◽  
Gram Negative Bacteria ◽  
Gram Negative ◽  
Content Type ◽  
Predominant Species ◽  
Carbapenem Resistant

ABSTRACTThis study was conducted to investigate the prevalence of and risk factors for colonization and acquisition of carbapenem-resistant (CR) Gram-negative bacteria (GNB) among patients admitted to intensive care units (ICUs) in two tertiary care hospitals in northern Thailand. Screening of rectal swab specimens for CR-GNB was performed on patients at ICU admission and discharge. The phenotypes and genotypes of all isolates were determined. Risk factors were analyzed by logistic regression analysis. The overall carriage rate of CR-GNB at admission was 11.6% (32/275), with the most predominant species carried beingAcinetobacter baumannii(n= 15), followed byKlebsiella pneumoniae(n= 9). The risk factor for CR-GNB colonization was hospitalization within the previous 6 months (P= 0.002). During the ICU stay, the rate of CR-GNB acquisition was 25.2% (52/206), with the most predominant species carried beingA. baumannii(n= 28) andK. pneumoniae(n= 13). Risk factors associated with CR-GNB acquisition were the use of an enteral feeding tube (P= 0.008) and administration of third-generation cephalosporins (P= 0.032) and carbapenems (P= 0.045). The most common carbapenemase genes inA. baumanniiandK. pneumoniaewereblaOXA-23/51andblaNDM, respectively. Patient-to-patient transmission was demonstrated in three cases, resulting in the acquisition of CRA. baumannii(2 cases) andK. pneumoniae(1 case) isolates from other patients who were admitted during the same period of time. This is the first Indochinese study screening patients, examining patients for the carriage of CR-GNB, and further demonstrating the transfer of CR-GNB isolates in ICUs. Our study suggests that effective infection control measures are required to limit the spread of CR-GNB within hospitals.

scholarly journals Determination of Risk Factors Associated With Isolation of Linezolid-Resistant Strains of Vancomycin-Resistant Enterococcus

2007 ◽  
Vol 28 (12) ◽  
pp. 1382-1388 ◽  
Author(s):  
Jason M. Pogue ◽  
David L. Paterson ◽  
A. William Pasculle ◽  
Brian A. Potoski
Keyword(s):  
Risk Factors ◽  
Medical Center ◽  
Horizontal Transmission ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Control Measures ◽  
Control Group ◽  
Solid Organ ◽  
Factors Associated ◽  
Vancomycin Resistant

Objective.To identify independent risk factors associated with isolation of linezolid-resistant, vancomycin-resistant Enterococcus (VRE).Design.A retrospective, case-case-control study.Setting.A tertiary care, academic medical center.Methods.VRE isolates from clinical cultures were retrospectively analyzed for linezolid resistance during our 18-month study period. Clinical data were obtained from electronic patient records, and the risk factors associated with isolation of linezolid-resistant VRE were determined by comparison of 2 case groups with a control group.Results.A total of 20% of the VRE isolates analyzed during the study period were linezolid resistant, and resistant isolates were most commonly recovered from the urine (40% of resistant isolates). Risk factors found to be associated with isolation of linezolid-resistant VRE were peripheral vascular disease and/or the receipt of a solid organ transplant, total parenteral nutrition, piperacillin-tazobactam, and/or cefepime. Only 25% of patients from whom linezolid-resistant VRE was isolated had previous linezolid exposure, and in the multivariate model this was not found to be a risk factor associated with the isolation of linezolid-resistant VRE.Conclusions.The results of this analysis suggest that there is horizontal transmission of linezolid-resistant VRE in our institution and highlight the need for improved infection control measures. Furthermore, the high incidence of linezolid-resistant VRE demands a reassessment of our empirical antibiotic selection for patients infected with VRE.

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