1212 infection control & hospital epidemiology october 2017, vol. 38, no. 10
incidence rates significantly increased among patients with ESBL-E. coli infections (range, 0–1.203 cases per 10,000 patient days; P<.001) but not for ESBL-Klebsiella infections (range, 0.837–1.011 per 10,000 patient days; P=0.785) among patients admitted to 16 community hospitals in North Carolina.17 Among 3 hospitals within the University of PennsylvaniaHealth System, a statistically significant increase in incidence rates were observed among patients with ESBL-E. coli or ESBL-Klebsiella infections after implementing the screening of urine cultures with E. coli or Klebsiella for ESBL (range during 2005–2009, 1.42–2.16 cases per 10,000 patient days preintervention and postintervention periods; P=.006).18 Conversely, from 1997 to 2002, Lipworth et al22 reported a
decrease in the incidence rate of ESBL-E. coli and ESBL-Klebsiella infections in 2 university-affiliated hospitals (Hospital A, 4.2–2.3 per 10,000 patient days; Hospital B, 4.5–3.5 per 10,000 patient days).22 However, the studies by Han et al18 and Lipworth et al22 focused on interventions targeting ESBL infections as the outcome. Lipworth et al implemented an antimicrobial formulary, whereas Han et al implemented a hospitalwide urine culture screening protocol.
Incidence of ESBL-Producing E. coli and Klebsiella Infections by Age
Of the 9 studies reviewed, 2 focused on infections in neonates,21,24 whereas the other 7 studies did not target a specific age group.
Community-Onset Infections
These studies found that the incidence of ESBL-E. coli infections ranged from 0 to 1.67 per 10,000 infants (Table 1).21,24 Larson et al21 reported zero ESBL-K. oxytoca infections and an incidence of ESBL-K. pneumoniae infections of 51.11 per 10,000 admissions. Swami et al25 stratified the incidence rates by age for 2005–
2009 and found statistically significant trends in incidence over time for patientswith ESBL-E. coli infections in the 18–64-year group (range, 7–15 cases per 100,000 person years; P=.03) and the 65–79-year group (range, 28–73 cases per 100,000 person years; P=.02), but they did not find a significant increase in the 0–17-year group (range, 3–8 cases per 100,000 person years; P=.43) or the >80-year group (range, 84–91 cases per 100,000 person years; P=.97).25
Community-Onset Versus Hospital-Onset ESBL Infections
Definitions for community-onset infections and hospital- onset infections varied by study (Table 2). Of the 6 studies that defined community-onset and hospital-onset infections, 1 study defined hospital-onset infection as an infection occurring >72 hours after admission, while 3 other studies defined this as infections occurring >48 hours after admission. In addition, 2 studies used the National Healthcare Safety Network definitions for device-associated infections (≥3 days after admission). Furthermore, 2 studies differentiated between healthcare-associated infections and hospital-onset infections, while the other 4 studies did not.
table 2. Definitions of Community-Onset Infections and Hospital-Onset Infections Study
Hospital-Onset Infections
Freeman et al17 Specimen collected ≤2 d after hospital admission
Specimen collected >2 d after hospital admission
Healthcare-Associated Infections Han et al18
Hidron et al19 Soe et al23
Lipworth et al22
N/A N/A
N/A
Specimen collected >48 h after hospital admission
National Healthcare Safety Network Definitions for device-associated infections (≥3 d after admission)
Specimen collected >48 h after hospital admission or ≤48 h if the patient had been hospitalized within 30 d prior to admission or if the patient had been transferred from an outside hospital or LTCF
Swami et al25
Specimen collected <72 h after hospital admission without any hospital-associated infection risk factors
Specimen collected >72 h after hospital admission
Specimen collected ≤2 d after hospital admission and had one of the following characteristics home health care, admission from a nursing home or long- term-care facility, transfer from another hospital, dependence on dialysis, or admission to a hospital within previous 12mo N/A
N/A N/A
Outpatients hospitalized 90 d before culture collection; were residents of a nursing home or long-term care facility; or had received home intravenous therapy, wound care, specialized nursing, urinary catheterization, dialysis, or chemotherapy with 30 d before culture collection
NOTE. N/A, not available; LTCF, long-term-care facility.
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