Carbapenemase-producing Enterobacteriaceae in a Portuguese hospital – a five-year retrospective study

Abstract

Background Our hospital experienced an outbreak of OXA-48-producing Enterobacteriaceae, triggering this study. We aimed to describe the population with carbapenemase-producing Enterobacteriaceae (CPE) in our hospital from 2014 to 2018, the phenotypic and genotypic characteristics of isolates, and strategies to stop the outbreak.Methods We performed a retrospective study, including every patient with CPE species in a clinical sample. Epidemiology, risk factors, treatment and outcomes were gathered from medical records.Results A total 113 patients were included, ranging from 5 in 2015 to 83 in 2018. In 2018 the number of CPE went from 4 in May to 20 in July. With the implemented measures, propagation stopped. Implantable devices were present in 36% of patients and open wounds in 34%. Antibiotics had been prescribed to 71% of patients in the prior 30 days and most of the patients had been hospitalized for more than 5 days prior to sample collection or had a hospital stay in the previous year. Klebsiella pneumoniae was the most common species (87%). OXA-48 (62%) and Klebsiella pneumoniae-carbapenemase (KPC) (15%) were the most common carbapenemases, with OXA-48 being implicated in the 2018 outbreak. The case fatality rate at 30 days was 32%. Combination therapy resulted in less mortality. Conclusions While KPC is the most common carbapenemase in Europe and Portugal, we experienced an important OXA-48 outbreak. Surveillance should be in place as these isolates are probably spreading. Effective communication, multidisciplinary team work and proper infection control measures are some of the best strategies during outbreaks.

Infection prevention and control strategies against carbapenem resistant Enterobacteriaceae – a systematic review

“…From the 26 studies conducted in hospitals, more than half (n = 17) were carried out in intensive care units (ICU). Others were carried out in a diverse set of departments in acute care units (Gorgulho et al, 2020;Trepanier et al, 2017), as cardiology wards (Decraene et al, 2018) or a liver unit (Martin et al, 2017). Twenty studies approached CRKP dissemination, two analysed CREC infection and/or colonisation and eight analysed both.…”

“…In Legeay et al (2018), IPC practitioners recommended that all scheduled care (clinical rounds, nurses rounds, sampling rounds) should leave the carriers/infected rooms to the end of the round. In another reviewed study, educational sessions were conducted by a multidisciplinary team, specifically constituted for that purpose (García-Arenzana et al, 2020) Gorgulho et al (2020) described that patients and families were also educated on IPC measures and instructed to warn the hospital staff in subsequent hospital visits of their previous infection/colonisation with CRE. Before and after quasi-experimental study, when modified IPC interventions were applied in addition to the standard IPC interventions, extensive external medical staff education, all consulting staff, rehabilitative physicians and external nurses had lectures and practical IPC education once a month (Li et al, 2019).…”

“…Small sample sizes (Battikh et al, 2017; Brkic et al, 2017; Borgmann et al, 2018; Chen et al, 2019; Gorgulho et al, 2020; Gu et al, 2018; Li et al, 2019), single-centre studies (Chen et al, 2019; Kong et al, 2019; Li et al, 2019; Madueno et al, 2017), small number of environmental samples (Decraene et al, 2018; Yan et al, 2019) and information on antimicrobial consumption limited to facilities records (Cienfuegos-Gallet et al, 2019) were indicated as limitations. Unknown CREC and CRKP transmission routes (Borgmann et al, 2018; Li et al, 2019) were also highlighted as relevant limitations as well as the retrospective (Chen et al, 2019; Madueno et al, 2017; Spencer et al, 2019) and observational (Decraene et al, 2018; Gorgulho et al, 2020) nature of data collection. Absence of ASC limited the studies by reducing the availability of important information on CRE incidence and prevalence (Cienfuegos-Gallet et al, 2019; Protonotariou et al, 2018).…”

Intra- and Extra-Hospital Dissemination of IMP-22-Producing Klebsiella pneumoniae in Northern Portugal: The Breach of the Hospital Frontier Toward the Community

“…Different clonal outbreaks caused by carbapenem-resistant K. pneumoniae have been reported in particular hospitals in Portugal; however, most if not all of the reported outbreaks were associated with non-metallo-carbapenemases (including KPC-3 and OXA-48; ( Conceicao et al, 2005 ; Rodrigues et al, 2014 ; Vubil et al, 2017 ; Manageiro et al, 2018 ; Mendes et al, 2018 ; Aires-de-Sousa et al, 2019 ; Perdigao et al, 2019 ; Gorgulho et al, 2020 ; Guerra et al, 2020 ; Lopes et al, 2020 ). In fact, only around 5% of the reported CPE in Portugal are associated with metallo-carbapenemases ( Manageiro et al, 2018 ; Gorgulho et al, 2020 ). Therefore, our report of an outbreak caused by IMP-22-producing K. pneumoniae has epidemiological relevance, complementing the landscape of carbapenemase-producing bacteria in Portugal.…”

“…However, in Portugal, the occurrence of MBL-producing Enterobacteriaceae in the clinical settings is apparently not common; only a few sporadic cases were reported, including a VIM-34-producing Klebsiella pneumoniae (Rodrigues et al, 2014) and a VIM-2-producing Klebsiella oxytoca (Conceicao et al, 2005). In fact, recent studies confirmed that among carbapenemase-producing Enterobacteriaceae (CPE), MBL-producing bacteria only represent 5% in Portugal (Manageiro et al, 2018;Gorgulho et al, 2020).…”