Infection Control & Hospital Epidemiology
Table 1. Number of Admissions and Demographic Characteristics of the Study Population Variable
Patients, no. Male, no. (%) SCI, no. (%)
Age, no. (%) <30 y 30–49 y 50–64 y ≥65 y
Note. SCI, spinal cord injury.
Total 4,180
3,114 (74.5) 3176 (76) 710 (17)
1,358 (32.5) 1170 (28) 940 (22.5)
2012 655
502 (77) 499 (76)
115 (17.5) 249 (38) 168 (26) 121 (18.5)
2013 721
540 (75) 558 (77.5)
120 (17) 227 (31.5) 200 (28) 172 (24)
369
2014 740
559 (75.5) 544 (73.5)
118 (16) 248 (33.5) 210 (28.5) 161 (22)
2015 725
540 (74.5) 561 (77.5)
121 (17) 210 (29) 194 (27) 198 (27)
2016 687
480 (70) 531 (77)
136 (20) 200 (29) 204 (30) 145 (21)
2017 652
493 (75.5) 483 (74)
100 (15) 224 (34) 194 (30) 143 (22)
Table 2. Colonization and Infection by Carbapenemase-Producing Enterobacteriaceae Variable
Total Patients admitted, no.
CPE carriers, no. (%) On admission During hospitalization
Incidence of CPE colonization during hospitalization/10,000 patient days Incidence of CPE-BSI/10,000 patient days
4,180
391 (9.3) 308 (8.1)
9.2 2.9
2012 655
66 (10) 58 (9.8)
10.4 4.1
2013 721
68 (9.4) 51 (7.8)
9.2 2.9
2014 740
56 (7.5) 44 (6.4)
7.9 1.4
2015 725
68 (9.3) 53 (8)
9.5 3.2
2016 687
69 (10) 60 (9.7)
10.7 2.9
2017 652
64 (9.8) 42 (7.1)
7.5 2.7
solution afterward. CPE carriers can participate in the activities that take place in common spaces (eg, occupational and recrea- tional therapy, meals) if they are able to comply with hand hygiene and are able to contain their stool and secretions. In ICU and RICU, where geographic separation of CPE-carriers
is not possible and patient’s clinical conditions usually do not allow participation in social activities, functional contact isolation is applied for all patients. Healthcare personnel receive periodic education (every
6 months) regarding hand hygiene practices and proper use of con- tact precaution. Adherence monitoring by direct observation is performed weekly by the infection control nurse. Patients and/ or their caregivers are involved in the infection control practices: they receive information about CPE-carriage, hand hygiene practices and proper use of contact precautions during dedicated educational meetings conducted by a charge nurse and ward physi- cians every 2 weeks.
Microbiology
Rectalswabswere collected using ESwab (Copan, Brescia, Italy).The swabs were plated into chromogenic plates, BBL CHROMagar CPE (Becton Dickinson, Erembodegem-Aalst, Belgium) orCHROMagar KPC (MEUS S.r.l. Kima, Padua, Italy), which were incubated aerobically at 37°C for 18–24 hours. Detection of CPE in blood cultures was performed using the BACTEC instrument (Becton Dickinson). Bottles were incubated for 6 days or until the instru- ment signaled a positive result. Identification and susceptibility testing of the presumptive CPE
colonies identified on the chromogenic plates and the positive blood cultures were performed using the Vitek-2 automated sys- tem (BioMérieux, Marcy l’Etoile, Craponne, France). Results were interpreted in accordance with the European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical break
points. From January 2012 to June 2016 mechanism of resistance to carbapenems was confirmed with phenotypic test using combined-disk commercially available kits (Biorad, Milan, Italy) and, as confirmatory method, the modified Hodges test, as described previously.4 From July 2016 to the end of the study period, presumptive CPE
colonies were tested with a first-level colorimetric test, Neo-Rapid CARB Screen Kit (Biolife Italiana, Milan, Italy). Carbapenem- resistant strains that yielded negative results to this first-level colori- metric test were also tested using a disk-diffusion method,KPC+MBL detection kit (Biolife Italiana,Milan, Italy) to confirm themechanism by which the organism gained resistance to carbapenems. In case of inconclusive results or suspected production of OXA-48, colonies were submitted to a molecular test, Xpert CarbaR (Cepheid, Milan, Italy).
Statistical analysis
Our endpoints were (1) prevalence of CPE rectal colonization on admission, (2) incidence of in-hospital acquisition of CPE coloni- zation, and (3) incidence of CPE-BSI. Descriptive statistics were obtained for all variables analyzed. Continuous variables were expressed using mean ± standard deviation (SD) if normally dis- tributed an using median and interquartile range (IQR) if nonnor- mally distributed. Categorical variables were expressed using absolute numbers and proportions. The χ2 for trend test was used to compare differences in the rates of CPE colonization and BSI during the study period.
Ethics
The study was conducted according to the principles of the Helsinki Declaration and was approved by the local institutional review board.
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