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Volume 68, Issue 3

The clinical significance of carbapenem-resistant Klebsiella pneumoniae rectal colonization in critically ill patients: from colonization to bloodstream infection Free

Abstract

Purpose . To highlight the clinical significance of carbapenem-resistant Klebsiella pneumoniae (CRKP) rectal colonization by examining the risk factors for CRKP rectal colonization and subsequent bloodstream infection (BSI) in critically ill patients.

Methodology . Prospective study of CRKP rectal colonization in an intensive care unit (ICU) during a 39-month period. CRKP strains isolated from both the blood cultures and corresponding rectal specimens (n=96) of patients were screened by PCR for the presence of antibiotic resistance-associated genes. Molecular analyses were conducted to investigate the clonal relatedness of CRKP strains from the rectal and blood specimens.

Results . Among the 498 patients, 226 were rectally colonized by CRKP, 48 of whom developed a CRKP BSI. The median time from hospital admission to the detection of CRKP rectal colonization was 8 days, while the median time from colonization to BSI was 4 days. The duration of ICU stay, patient/nurse ratio and prior use of antianaerobic antimicrobials were associated with CRKP rectal colonization. No specific factor was associated with BSIs in the colonized patients. The bla KPC-2 gene was detected in all 96 strains, which were all classified as sequence type ST-258. Representative pairs (n=48) of CRKP strains colonizing and infecting the same patient shared the same pulsotype.

Conclusion . Our results indicate that hospitalized patients become infected with their colonizing strains, supporting the strong association between colonization and BSI. Limiting antianaerobic antimicrobial administration, reducing the duration of ICU stay and maintaining a low patient/nurse ratio are possible strategies to restrict rectal CRKP colonization in ICUs.

  • Received:
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Keyword(s): bloodstream infections , Carbapenem-resistant Klebsiella pneumoniae , colonization , intensive care unit and risk factors
© 2019 The Authors
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2019-01-30
2024-04-19
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References

  1. Munoz-Price LS, Poirel L, Bonomo RA, Schwaber MJ, Daikos GL et al. Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases. Lancet Infect Dis 2013; 13:785–796 [View Article]
     [Google Scholar]
  2. Yigit H, Queenan AM, Anderson GJ, Domenech-Sanchez A, Biddle JW et al. Novel carbapenem-hydrolyzing beta-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob Agents Chemother 2001; 45:1151–1161 [View Article]
     [Google Scholar]
  3. Arnold RS, Thom KA, Sharma S, Phillips M, Kristie Johnson J et al. Emergence of Klebsiella pneumoniae carbapenemase-producing bacteria. South Med J 2011; 104:40–45 [View Article]
     [Google Scholar]
  4. Centers for Disease Control and Prevention Vital signs: carbapenem-resistant Enterobacteriaceae. MMWR Morb Mortal Wkly Rep 2013; 62:165–170
     [Google Scholar]
  5. Department of Health and Social Care 2013; Antimicrobial resistance poses ‘catastrophic threat’. https://www.gov.uk/government/news/antimicrobial-resistance-poses-catastrophic-threat-says-chief-medical-officer--2
  6. European Society of Clinical Microbiology and Infectious Diseases 2015; Diseases. Antibiotic armageddon in UK and Europe by 2025. http://www.biospace.com/news/escmid-release-antibiotic-armageddon-in-uk-and/373428
  7. Lee CR, Lee JH, Park KS, Kim YB, Jeong BC et al. Global dissemination of carbapenemase-producing Klebsiella pneumoniae: epidemiology, genetic context, treatment options, and detection methods. Front Microbiol 2016; 7:895 [View Article]
     [Google Scholar]
  8. Maltezou HC, Giakkoupi P, Maragos A, Bolikas M, Raftopoulos V et al. Outbreak of infections due to KPC-2-producing Klebsiella pneumoniae in a hospital in Crete (Greece). J Infect 2009; 58:213–219 [View Article]
     [Google Scholar]
  9. European Centre for Disease Prevention and Control Surveillance of antimicrobial resistance in Europe. Annual report of the European antimicrobial resistance surveillance network (EARS-Net). Stockholm: ECDC; 2017 https://ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-resistance-europe-2017
  10. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J 1977; 2:1315–1317 [View Article]
     [Google Scholar]
  11. Selden R, Lee S, Wang WL, Bennett JV, Eickhoff TC. Nosocomial klebsiella infections: intestinal colonization as a reservoir. Ann Intern Med 1971; 74:657–664 [View Article]
     [Google Scholar]
  12. Jarvis WR, Munn VP, Highsmith AK, Culver DH, Hughes JM. The epidemiology of nosocomial infections caused by Klebsiella pneumoniae. Infect Control 1985; 6:68–74 [View Article]
     [Google Scholar]
  13. Falcone M, Russo A, Iacovelli A, Restuccia G, Ceccarelli G et al. Predictors of outcome in ICU patients with septic shock caused by Klebsiella pneumoniae carbapenemase–producing K. pneumoniae. Clin Microbiol Infect 2016; 22:444–450 [View Article]
     [Google Scholar]
  14. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13:818–829
     [Google Scholar]
  15. Kreger BE, Craven DE, Carling PC, McCabe WR. Gram-negative bacteremia. III. reassessment of etiology, epidemiology and ecology in 612 patients. Am J Med 1980; 68:332–343
     [Google Scholar]
  16. Finegold SM. Anaerobic gram-negative bacilli. In Medical Microbiology Chapter 20 Galveston,TX: University of Texas Medical Branch at Galveston; 1996
     [Google Scholar]
  17. Vrioni G, Daniil I, Voulgari E, Ranellou K, Koumaki V et al. Comparative evaluation of a prototype chromogenic medium (ChromID CARBA) for detecting carbapenemase-producing Enterobacteriaceae in surveillance rectal swabs. J Clin Microbiol 2012; 50:1841–1846 [View Article]
     [Google Scholar]
  18. European Society of Clinical Microbiology and Infectious Diseases 2013; EUCAST guidelines on detection of resistance mechanisms. EUCAST v 1.0 (2013-12-11). http://www.eucast.org
  19. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16:128–140 [View Article]
     [Google Scholar]
  20. Papagiannitsis CC, Izdebski R, Baraniak A, Fiett J, Herda M et al. Survey of metallo-beta-lactamase-producing Enterobacteriaceae colonizing patients in European ICUs and rehabilitation units, 2008–11. J Antimicrob Chemother 2015; 70:1981–1988 [View Article]
     [Google Scholar]
  21. Diancourt L, Passet V, Verhoef J, Grimont PA, Brisse S. Multilocus sequence typing of Klebsiella pneumoniae nosocomial isolates. J Clin Microbiol 2005; 43:4178–4182 [View Article]
     [Google Scholar]
  22. van Belkum A, Tassios PT, Dijkshoorn L, Haeggman S, Cookson B et al. Guidelines for the validation and application of typing methods for use in bacterial epidemiology. Clin Microbiol Infect 2007; 13:1–46 [View Article]
     [Google Scholar]
  23. Conlan S, Park M, Deming C, Thomas PJ, Young AC et al. Plasmid dynamics in KPC-positive Klebsiella pneumoniae during long-term patient colonization. mBio 2016; 7: [View Article]
     [Google Scholar]
  24. Souli M, Galani I, Antoniadou A, Papadomichelakis E, Poulakou G et al. An outbreak of infection due to beta-Lactamase Klebsiella pneumoniae Carbapenemase 2-producing K. pneumoniae in a Greek University Hospital: molecular characterization, epidemiology, and outcomes. Clin Infect Dis 2010; 50:364–373 [View Article]
     [Google Scholar]
  25. Zarkotou O, Pournaras S, Tselioti P, Dragoumanos V, Pitiriga V et al. Predictors of mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae and impact of appropriate antimicrobial treatment. Clin Microbiol Infect 2011; 17:1798–1803 [View Article]
     [Google Scholar]
  26. Bonten MJ, Weinstein RA. The role of colonization in the pathogenesis of nosocomial infections. Infect Control Hosp Epidemiol 1996; 17:193–200 [View Article]
     [Google Scholar]
  27. Magiorakos AP, Burns K, Rodríguez Baño J, Borg M, Daikos G et al. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control 2017; 6:113 [View Article]
     [Google Scholar]
  28. Papadimitriou-Olivgeris M, Marangos M, Fligou F, Christofidou M, Sklavou C et al. KPC-producing Klebsiella pneumoniae enteric colonization acquired during intensive care unit stay: the significance of risk factors for its development and its impact on mortality. Diagn Microbiol Infect Dis 2013; 77:169–173 [View Article]
     [Google Scholar]
  29. Nouvenne A, Ticinesi A, Lauretani F, Maggio M, Lippi G et al. Comorbidities and disease severity as risk factors for carbapenem-resistant Klebsiella pneumoniae colonization: report of an experience in an internal medicine unit. PLoS One 2014; 9:e110001 [View Article]
     [Google Scholar]
  30. Jandhyala SM, Talukdar R, Subramanyam C, Vuyyuru H, Sasikala M et al. Role of the normal gut microbiota. World J Gastroenterol 2015; 21:8787–8803 [View Article]
     [Google Scholar]
  31. Jernberg C, Lofmark S, Edlund C, Jansson JK. Long-term impacts of antibiotic exposure on the human intestinal microbiota. Microbiology 2010; 156:3216–3223 [View Article]
     [Google Scholar]
  32. Stecher B, Hardt WD. Mechanisms controlling pathogen colonization of the gut. Curr Opin Microbiol 2011; 14:82–91 [View Article]
     [Google Scholar]
  33. Carlet J. The gut is the epicentre of antibiotic resistance. Antimicrob Resist Infect Control 2012; 1:39 [View Article]
     [Google Scholar]
  34. Gorrie CL, Mirčeta M, Wick RR, Edwards DJ, Thomson NR et al. Gastrointestinal carriage is a major reservoir of Klebsiella pneumoniae infection in intensive care patients. Clin Infect Dis 2017; 65:208–215 [View Article]
     [Google Scholar]
  35. Perez F, Pultz MJ, Endimiani A, Bonomo RA, Donskey CJ. Effect of antibiotic treatment on establishment and elimination of intestinal colonization by KPC-producing Klebsiella pneumoniae in mice. Antimicrob Agents Chemother 2011; 55:2585–2589 [View Article]
     [Google Scholar]
  36. Papadimitriou-Olivgeris M, Marangos M, Fligou F, Christofidou M, Bartzavali C et al. Risk factors for KPC-producing Klebsiella pneumoniae enteric colonization upon ICU admission. J Antimicrob Chemother 2012; 67:2976–2981 [View Article]
     [Google Scholar]
  37. Ling ML, Tee YM, Tan SG, Amin IM, How KB et al. Risk factors for acquisition of carbapenem resistant Enterobacteriaceae in an acute tertiary care hospital in Singapore. Antimicrob Resist Infect Control 2015; 4:26 [View Article]
     [Google Scholar]
  38. Jiao Y, Qin Y, Liu J, Li Q, Dong Y et al. Risk factors for carbapenem-resistant Klebsiella pneumoniae infection/colonization and predictors of mortality: a retrospective study. Pathog Glob Health 2015; 109:68–74 [View Article]
     [Google Scholar]
  39. Kwak YG, Choi SH, Choo EJ, Chung JW, Jeong JY et al. Risk factors for the acquisition of carbapenem-resistant Klebsiella pneumoniae among hospitalized patients. Microb Drug Resist 2005; 11:165–169 [View Article]
     [Google Scholar]
  40. Schechner V, Kotlovsky T, Kazma M, Mishali H, Schwartz D et al. Asymptomatic rectal carriage of blaKPC producing carbapenem-resistant Enterobacteriaceae: who is prone to become clinically infected?. Clin Microbiol Infect 2013; 19:451–456 [View Article]
     [Google Scholar]
  41. Schwaber MJ, Klarfeld-Lidji S, Navon-Venezia S, Schwartz D, Leavitt A et al. Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality. Antimicrob Agents Chemother 2008; 52:1028–1033 [View Article]
     [Google Scholar]
  42. Rafii F, Sutherland JB, Cerniglia CE. Effects of treatment with antimicrobial agents on the human colonic microflora. Ther Clin Risk Manag 2008; 4:1343–1357 [View Article]
     [Google Scholar]
  43. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003; 163:972–978
     [Google Scholar]
  44. Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res 2003; 52:71–79 [View Article]
     [Google Scholar]
  45. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care–associated infection. Am J InfectControl 2012; 40:486–490 [View Article]
     [Google Scholar]
  46. Gregory CJ, Llata E, Stine N, Gould C, Santiago LM et al. Outbreak of carbapenem-resistant Klebsiella pneumoniae in Puerto Rico associated with a novel carbapenemase variant. Infect Control Hosp Epidemiol 2010; 31:476–484 [View Article]
     [Google Scholar]
  47. Borer A, Saidel-Odes L, Eskira S, Nativ R, Riesenberg K et al. Risk factors for developing clinical infection with carbapenem-resistant Klebsiella pneumoniae in hospital patients initially only colonized with carbapenem-resistant K. pneumoniae. Am J Infect Control 2012; 40:421–425 [View Article]
     [Google Scholar]
  48. Amit S, Mishali H, Kotlovsky T, Schwaber MJ, Carmeli Y. Bloodstream infections among carriers of carbapenem-resistant Klebsiella pneumoniae: etiology, incidence and predictors. Clin Microbiol Infect 2015; 21:30–34 [View Article]
     [Google Scholar]
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The clinical significance of carbapenem-resistant Klebsiella pneumoniae rectal colonization in critically ill patients: from colonization to bloodstream infection
J. Med. Microbiol. 68, 326 (2019); https://doi.org/10.1099/jmm.0.000921
/content/journal/jmm/10.1099/jmm.0.000921
/content/journal/jmm/10.1099/jmm.0.000921
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