Molecular Epidemiology and Risk Factors for Extended-Spectrum β-Lactamase–Producing Enterobacterales in Long-Term Care Residents

Abstract

Objectives: We aimed to assess the burden of extended-spectrum b-lactamase (ESBL)-producing Enterobacterales in Swiss long-term care facilities (LTCFs) to describe the molecular epidemiology, describe the intrainstitutional and regional clusters of resistant pathogens, and identify independent institution-and resident-level factors associated with colonization. Design: Cross-sectional study. Setting and Participants: From August to October 2019, we performed a point prevalence study among residents from 16 LTCFs in Western and Eastern Switzerland (8 per region). Methods: Residents underwent screening for ESBL-producing Enterobacterales (ESBL-E); whole-genome sequencing (WGS) was performed. We gathered institution-level (eg, number of beds, staff-resident ratio, alcoholic hand rub consumption) and resident-level [eg, anthropometric data, time in facility, dependency, health care exposure, antibiotic treatment, proton-pump inhibitor (PPI) use] characteristics. Factors associated with colonization were identified using a generalized linear model. Results: Among 1185 eligible residents, 606 (51%) consented to the study. ESBL-E prevalence was 11.6% (70/606), ranging from 1.9% to 33.3% between institutions, with a median of 12.5% in the West and 6.9% in the East (P ¼ .03). Among 59 Escherichia coli (from 58 residents), multilocus sequence type (ST) 131 was most common (n ¼ 43/59, 73%), predominantly its subclone H30R1 (n ¼ 37/43, 86%). WGS data identified multiple intrainstitutional and regional clusters. Independent risk factors for ESBL carriage were previous ESBL colonization [adjusted odds ratio (aOR) 23.5, 95% confidence interval (CI) 6.6-83.8, P < .001), male gender (aOR 2.6, 95% CI 1.5-4.6, P ¼ .002), and use of PPIs (aOR 2.2, 95% CI 1.2-3.8, P ¼ .01). Conclusions and Implications: Overall ESBL-E prevalence in Swiss LTCF residents is low. Yet, we identified several clusters of residents with identical pathogens within the same institution. This implies that particularly affected institutions might benefit from targeted infection control interventions. PPI use was the only modifiable factor associated with carriage of ESBL producers. This study adds to the growing list

Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers

“…For instance, in Switzerland (2010–2020), 10.5% of the long-term care facilities (LTCF) residents were colonized with ESBL- Ec , of which 58% belonged to the pandemic sequence type (ST) 131 lineage [ 73 ]. Consistent results were obtained in a more recent national Swiss study (2019), with an ESBL- Ent carriage of 11.6% and again a high prevalence of ST131 Ec strains [ 74 ]. In an Italian study (2008), 64% of the LTCF residents were colonized with ESBL- Ent , while 6.3% had CPE.…”

Community carriage of ESBL-producingEscherichia coliandKlebsiella pneumoniae: A cross-sectional study of risk factors and comparative genomics of carriage and clinical isolates

“…As antibiotic use has been found as a risk factor for resistance in many other studies, 14,15,22 we cannot rule out that antibiotic use plays a role in ESBL-E carriage. There are reports identifying an association between the use of gastric acid suppressive medication and intestinal colonization or infections with ESBL-E. 18,21,23,33,34,46…”

“…Several risk factors for ESBL-E gastrointestinal carriage have been described. However, these have, with a few exceptions 13,14 , mainly been investigated in small and/or selected study populations, such as international travelers 15 , patients with gastroenteritis 16 , patients recruited by general practitioners 17 , persons with recent healthcare contact 18 , pregnant women 19 , children 20 or persons living in a livestock-dense area 21 . Many studies have identified international travel as a risk factor for ESBL acquisition, whilst the significance of sex, age, antibiotic or proton pump inhibitor use, hospitalization and diet are conflicting.…”

“…Many studies have identified international travel as a risk factor for ESBL acquisition, whilst the significance of sex, age, antibiotic or proton pump inhibitor use, hospitalization and diet are conflicting. [13][14][15]17,18,[22][23][24] We have comprehensive knowledge of the prevalence and population structure of clinical ESBL-E isolates showing a dominance of CTX-M-group ESBL enzymes and the association with specific extraintestinal pathogenic E. coli (ExPEC) and multidrug-resistant K. pneumoniae high-risk clones. [25][26][27][28] Large-scale genomic studies have identified specific subclades of E. coli sequence type (ST) 131 and K. pneumoniae ST307 as major contributors to the increasing prevalence of ESBL infections.…”

“…Many studies have identified international travel as a risk factor for ESBL acquisition, whilst the significance of sex, age, antibiotic or proton pump inhibitor use, hospitalization and diet are conflicting. 13–15,17,18,22–24…”