370 Results
During the study period, we observed 4,180 patients with a mean length of stay of 79 ± 4 days, for overall 333,484 patient days (Table 1). Overall, 9.3% of patients were CPE rectal carriers on admission, and 8.1% acquired colonization during hospitalization. A CPE-BSI was diagnosed in 96 of 699 colonized patients (14%). No CPE-BSI occurred among subjects who were not colonized, and during the study period no otherCPE infections were identified. Aslight decrease ofCPE prevalence on admission (from 10% to
7.5%; P = .06) was observed from 2012 to 2014, but this trend was not confirmed in 2015. Likewise, the incidence ofCPE colonization and CPE-BSI decreased significantly from 2012 to 2014: from 10.4 to 7.9 per 10,000 patient days (P = .03) and from 4.1 to 1.4 per 10,000 patient days (P = .02), respectively. However, these rates increased in 2015, when the burden of CPE carriers was higher. During 2016, the number of CPE carriers on admission
increased together with the rates of CPE colonization during hos- pitalization, whereas in 2017 the number of CPE carriers on admis- sion remained stable but the incidence of CPE cross transmission decreased. Finally, a statistically nonsignificant reduction of the incidence of CPE-BSI was observed from 2015 to 2017: from 3.2 to 2.6 per 10,000 patient days (P = .10) (Table 2). Overall, the differences in the rates of CPE colonization and CPE-BSI observed during the study period were not statistically significant (P = .36 and P = .41, respectively).
Discussion
In this study, we described the burden of CPE in an Italian neuro- rehabilitation hospital during a 6-year period. At our knowledge, this is the first longitudinal report on the epidemiology of CPE in this setting. Our findings show a reduction of the CPE burden during the first 3 years of the study period that was not confirmed subsequently, which illuminates the underlying difficulties in maintaining the results over time, especially in the face of the increase of colonized patients entering the hospital. In 2015,Hayden et al1 described the implementation of a bundled
intervention to reduce KPC colonization and infection in LTCAHs that led to a sustained decrease in KPC cross transmission and bloodstream infections. Our results were not as favorable, but the length of study period (6 years vs 12–19 months) and the epidemio- logical context (prevalence of CPE carriers on admission the baseline incidence of CPE-BSI of 9% vs 20% and 0.4 vs 0.9 per 1,000 patient days, respectively) are different. Moreover, some effective infection control measures could not be applied routinely. Strict patient isolation could not be routinely applied because reintegration in the community is amain goal of rehabilitation programs and because participation in social activities is a cornerstone of the rehabilitation process. In addition, universal chlorhexidine bathing cannot be routinely carried out because open wounds (eg, pressure ulcers and surgical and traumatic wounds) are extremely frequent in our population. Finally, the attendance at educational activities regarding infection control practices wasmandatory for healthcare workers but voluntary for patients’ relatives and caregivers, who are directly involved in patient care. In our study, the application of the infection control measures
was effective in containing in-hospitalCPE colonization, especially when the amount of imported CPE carriers was lower. Their number can be considered related to the effectiveness of the infection control measures applied in the acute-care setting, and the reduction observed in 2014 is probably related to some successful Italian experiences.5,6 These measures, however, had
Sara Tedeschi et al
been implemented only at a hospital or local level, and their effectiveness was not sustained overtime.7 Colonization pressure is an important risk factor for acquiring colonization,8 which underscores the need for comprehensive infection control pro- grams implemented on a national level. Such programs are lacking in Italy. The first limitation of this study is its single-center design.
However, MRI is one of the largest rehabilitation hospitals in Italy, and it admits patients coming from acute-care hospitals located all over the country. Thus, our data can be considered rep- resentative of the national epidemiology. Second, molecular tests for the detection of resistance genes were not routinely available during the study period. These techniques have been shown to be more sensitive than culture on chromogenic media to identify CPE on surveillance rectal swabs, so we could have underestimated the real burden of CPE colonization.9 To conclude, our study has demonstrated a high burden of CPE
colonization and infection in the neurorehabilitation setting in Italy, consistent with national epidemiology. The effectiveness of infection control measures was directly affected by the CPE epi- demiology outside the facility: the higher the rate of CPE carriers on admission, the higher the rates of new CPE carriers during the hospital stay and of CPE infections. However, during the study period, the rates of CPE-BSI decreased below the initial rate of 4.2 per 10,000 patient days, suggesting that infection control measures may have failed in reducing cross transmission but, together with the reduction of the antibiotic pressure reached with a concomitant antimicrobial stewardship program,3 they may have contributed to prevent CPE infections among CPE carriers. Surely, improving the attention to CPE colonization prevention
and management in acute-care hospitals, thus reducing the burden of CPE carriers who access the rehabilitation setting, remains of pivotal value.
Author ORCIDs. Sara Tedeschi, 0000-0001-9546-2811 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.
References 1. Hayden MK, Lin MY, Lolans K, et al. Prevention of colonization and infec- tion byKlebsiella pneumoniae carbapenemase-producing Enterobacteriaceae in long-term acute-care hospitals. Clin Infect Dis 2015;60:1153–1161.
2. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control 2009;37:85–93.
3. Tedeschi S, Trapani F, Giannella M, et al.Anantimicrobial stewardship pro- gram based on systematic infectious disease consultation in a rehabilitation facility. Infect Control Hosp Epidemiol 2017;38:76–82.
4. Pignanelli S, Zaccherini P, Schiavone P, Nardi Pantoli A, Pirazzoli S, Nannini R. In vitro antimicrobial activity of several antimicrobial agents against Escherichia coli isolated from community-acquired uncom- plicated urinary tract infections. Eur Rev Med Pharmacol Sci 2013;17: 206–209.
5. Viale P, Tumietto F, Giannella M, et al. Impact of a hospital-wide multifac- eted program for reducing carbapenem-resistant Enterobacteriaceae infections in a large teaching hospital in northern Italy. Clin Microbiol Infect 2015;21:242–247.
6. Agodi A, Voulgari E, Barchitta M, et al. Containment of an outbreak of KPC-3-producing Klebsiella pneumoniae in Italy. J Clin Microbiol 2011;49:3986–3989.
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