Antimicrobial Stewardship Program, COVID-19, and Infection Control: Spread of Carbapenem-Resistant Klebsiella Pneumoniae Colonization in ICU COVID-19 Patients. What Did Not Work?

Abstract

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the “daily-ICU round strategy” and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4–5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization.

Spread of Carbapenem-Resistant Gram-Negatives and Candida auris during the COVID-19 Pandemic in Critically Ill Patients: One Step Back in Antimicrobial Stewardship?

“…Moreover, we postulated a negative impact of COVID-19 on antimicrobial stewardship programs, an issue reported in a speculative manner in various reviews and editorials. To the best of our knowledge, only one real-life report describes the acquisition of CR-Kp colonization among COVID-19 patients [15], while two centers reported an increase in C. auris infections in COVID-19 patients [16,17]. We supposed that the main drivers of an increase in antimicrobial resistance during COVID-19 in our hospital were the use of broad-spectrum antimicrobials and horizontal spread of resistant strains.…”

Impact of the COVID-19 Pandemic on Antimicrobial Consumption and Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections

“…In this sense, a retrospective observational study analysed the bimonthly incidence of carbapenem-resistant Enterobacteriaceae (CRE) colonisation and the incidence of CRE acquisition in an Italian intensive care unit from January 2019 to June 2020 and reported that the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March–April 2020. Authors stated that the high intensity of care, the need to be changed in a prone position and prolonged contact with the patient, and the presence of health personnel without work experience in intensive care setting contributed to the spread of CRE acquisition [ 29 ]. In our centre, the incidence and death rates of hospital-acquired candidemia and MDR bacterial BSI showed a stable trend and, moreover, the quality of care measured by the percentage of deaths in patients diagnosed with BSI did not deteriorate.…”

Implications of COVID-19 Pandemic on the Emergence of Antimicrobial Resistance: Adjusting the Response to Future Outbreaks

“…Experience from a teaching hospital that has implemented antimicrobial stewardship measures at an ICU with special attention on infection control measures, the carbapenem-resistant Enterobacteriaceae incidence rose from 6.7% in 2019 to up to 50% in March and April of 2020. Obviously, with staff training and implementation of the antimicrobial stewardship measures, a reduction in carbapenem-resistant Enterobacteriaceae was expected [ 76 ].…”