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likely to be higher than that observed in this survey. VRE infec- tion prevalence is less subject to detection bias. Fortunately, VRE infection in Canada remains uncommon with only 23 patients identified with VRE infection (0.07 per 100 inpatients). Data from CARSS showed a steady increase of the infection rate of VRE between 2008 and 2012.2 From 2012 to 2014, the rate decreased but did not return to the previous lower rate of 2008. However, this rate remains much lower in the Canadian hospitals than in the United States facilities. In the United States, Enterococcus spp remain the second most common cause of healthcare-associated infections. According to the NHSN data from 2014, 29.8% of enterococci healthcare-associated infections were resistant to vancomycin.12 The percentage of invasive Enterococcus faecium with resistance to vancomycin varies greatly among European countries such as Norway, Sweden, and Iceland, which reported no resistance, whereas Ireland reported resistance as high as 46%.13 A significant increase in the proportion of vancomycin- resistant E. faecium occurred in 12 of the 26 EARS-Net partici- pating countries between 2012 and 2015. CREs represent a growing concern because many of these
organisms are resistant to other classes of antibiotics as well. Very few treatment options exist for patients infected with these iso- lates, and outcomes might be poorer than infection with non-CRE organisms.14 The threat of the emergence and dissemination of mcr-1 encoding colistin resistance further increases the danger of CREs.15 Our survey showed that CREs remain infrequently identified in Canadian hospitals. However, they were reported from more hospitals in 2016 (15%) compared to 2012 (7%). Also, the mean prevalence reported from hospitals that submitted CRE data for the 2012 and 2016 survey was slightly higher (0.10 per 100 inpatients) than in 2012 (0.05 per 100 inpatients). Impor- tantly, more hospitals were performing active surveillance for CREs in 2016 compared to 2012. Fortunately, infections remain very rare, with only 3 infections reported from all 160 partici- pating hospitals. Unsurprisingly, as it is observed worldwide, Klebsiella spp most frequently exhibit carbapenem resistance. Although the number of organisms was very small, the over- representation of the NDM carbapenemase enzyme identified is surprising because the KPC enzyme is usually the most frequent enzyme identified in carbapenem resistance in Canada.2 Pro- spective surveillance in Canada is currently performed by the Canadian Nosocomial Infection Surveillance Program (CNISP) in 58 hospitals, and CNISP data have shown that the CRE rate did not change significantly from 2010 to 2014 (0.19 and 0.22 per 10,000 patient days respectively).2 In Europe, CRE incidence varies widely from country to country, but a global an increase occurred in the proportion of K. pneumoniae that were resistant to carbapenem from 2010 to 2014.13 The CDC in the United States changed in 2015 the CRE surveillance definition to increase sensitivity by including all Enterobacteriaceae with resistance to at least 1 of the carbapenem antibiotics or documentation that the isolate possessed a carbapenemase enzyme.16 According to 2013 CDC data, 11% of K. pneumoniae and 2% of E. coli healthcare- associated infections were resistant to carbapenem antibiotic.17 True prevalence of ESBLs is very hard to assess because the
definition for what defines a potentially transmittable ESBL varies from one center to another across Canada. Also, a minority of hospitals perform active screening for these organisms. The ESBL infection prevalence rate is more reliable than the total ESBL prevalence because it is less affected by detection bias. Our data show that the mean prevalence for ESBL infection remained the same (0.4 per 100 inpatients) in 2012 and in 2016.
Philippe Martin et al
A secondary objective of this study was to identify institutional characteristics associated with prevalence of AROs. Although we did find some significant associations, such as hospital size >500 beds and higher prevalence of VRE and CDI, these do not necessarily imply a causal relationship. The 2016 point-prevalence survey was conducted during the peak of the influenza season in most of Canada. Nevertheless, the 5 studied AROs still accounted for >60% of additional precautions used in Canadian hospitals. Because putting additional measures in place requires significant resources and physical space, a further increase in the prevalence of these AROs could have adverse effects such as bed blocking and overcrowding. We believe that the results of this survey are representative of
Canadian acute-care hospitals with at least 50 inpatient beds. Overall, 106 hospitals participated in all 3 surveys, allowing for an accurate analysis of the trends of AROs prevalence over time. The results are not applicable to pediatric, psychiatric, rehabilitation, or long-term care facilities. We have identified some differences between our AROs prevalence results and the incidence data as reported by the Canadian surveillance programs; overall, we did not find significant changes in the prevalence, while the incidences for CDI, MRSA and VRE infection decreased. These findings could, in part, be related to the limited ability to detect changes in the prevalence of organisms that are likely to colonize an individual for prolonged periods of time. Thus, prevalence data compliment those provided by determining incidence to obtain a more robust understanding of the burden of disease attributable to AROs in hospital settings. Varied screening practices can cause detection bias, and sampling variations and may have affected the identifi- cation of patients colonized with these organisms. In conclusion, these data provide national prevalence rates for
MRSA, VRE, ESBLs, CREs and CDI among adult inpatients in Canadian hospitals. The rates have remained similar for MRSA and CDI from 2010 to 2016. VRE prevalence significantly increased from 2010 to 2012 but remained similar when com- paring 2016 to 2012. However, fewer hospitals are now screening for VRE colonization, which will limit our capacity to monitor real change over time. The number of VRE infections in Canadian hospitals remains low, but the impact of recent changes in VRE screening on infection rates has yet to be determined. CREs were identified in more hospitals in 2016 than in 2012, perhaps because of increased awareness and screening, but they remain infre- quently identified in Canadian hospitals. Ongoing national sur- veillance for AROs is important to evaluate potential changes in the epidemiology of diseases caused by these bacteria.
Acknowledgments. We thank the infection control and prevention profes- sionals at participating sites who collected and submitted data for the survey.
Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.279
References
1. Watkins RR, Bonomo RA. Overview: global and local impact of antibiotic resistance. Infect Dis Clin North Am 2016;30:313–322.
2. Public Health Agency of Canada. Canadian Antimicrobial Resistance Surveillance System—Report 2016. Guelph ON: PHAC; 2016.
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