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Carbapenemase-producing Klebsiella pneumoniae (KPC) infection outbreak in Italy: Report of an experience with elderly frail patients
Abstracts
medical care, to raise the “compliances“ and improve the living standards of HIV/AIDS patients. doi:10.1016/j.ejim.2013.08.503
ID: 515 Carbapenemase-producing Klebsiella pneumoniae (KPC) infection outbreak in Italy: Report of an experience with elderly frail patients A. Nouvennea, A. Ticinesia, N. Cerundoloa, I. Morellib, L. Guidab, B. Pratib, G. Ragnib, E. Ridoloa, L. Borghia, T. Meschia a
Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy b Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
Objectives: Carbapenemase-producing Klebsiella pneumoniae (KPC) is an emerging multidrug resistant nosocomial pathogen. It may cause epidemic outbreaks of serious systemic infections in hospital in-patients with a high degree of frailty and a large number of comorbidities. Its intrinsic resistance to almost every antibiotic therapy makes these infections particularly difficult to treat, with a documented mortality rate next to 60%. The first epidemic outbreak in Italy was described in 2009, while our hospital was involved for the first time in July 2011. The aims of this research were therefore to describe the characteristics of a KPC outbreak in a subacute critical care ward and to assess the effect of sanitary measures (bed isolation vs cohort isolation). Materials and methods: At Internal Medicine and Critical Subacute Care Unit of Parma University Hospital we consecutively studied all patients infected by KPC (133 patients, M 75, F 58, mean age 79 ± 12 years) from August 2011 to May 2012. We recorded main diagnosis, comorbidities, length of hospital stay, outcome, and anatomical district of KPC isolation for all patients. Following Emilia–Romagna Regional Guidelines, all infected patients, all contacts of these patients and all bedridden patients of the same ward were subdued to a rectal tampon for KPC detection every 7 days. From October 2011 to February 2012 we also activated a 14-bed isolation ward applying a staff cohorting management. In the previous and following period we instead applied the traditional contact isolation approach. Results: During the first two months of epidemic outbreak with the traditional contact isolation approach we observed 41 new cases (23 in the first month and 18 in the second month). The cases were limited to an average of 8 cases per month (range 3–13) in the following 5 months after the activation of the 14-bed staff cohorting ward. After the restoration of the usual contact isolation measures, we observed a new increase in incidence rates (respectively 15 and 18 cases in April and May 2012). Mean length of hospital stay of KPC-positive patients was significantly longer than that of other patients admitted to our unit (35 ± 24 vs 18 ± 12 days, p b 0.001). In most cases, KPC was isolated in rectal tampon cultures. 29 patients out of 133 (14%) deceased during hospital stay. Most of the deaths were attributable to septic shock and occurred in the first two months of the epidemic outbreak. The most prevalent comorbidities were cardiopathies (84/133 patients, 64%) and COPD (72/133 patients, 54%). Conclusions: KPC infection is quickly emerging as a relevant health issue, especially in elderly frail inpatients with multiple comorbidities. Mortality in our setting has however been lower than that described in the literature. Staff cohorting isolation measures may be effective to limit the epidemic spread, although a periodicity in KPC infections, like the one observed for other Enterobacteriaceae, cannot be excluded. doi:10.1016/j.ejim.2013.08.504
e197
ID: 576 Microbial isolates in blood cultures in an internal medicine department J. Trindade Nave, G. Nobre de Jesus, L. Santos Pinheiro, J. Meneses Santos, M. Lucas, R.M.M. Victorino Internal Medicine 2, Hospital Santa Maria, Lisboa, Portugal
Introduction: Blood cultures (BC) remain the major diagnostic test for hematogenic infections. Their results may allow the de-escalation of antibiotic therapy reducing the selective pressure on resistant bacterial strains. Studies show a positivity rate of 9–20% with 5–9% of true positives and only 0.3–1.6% of alterations in antibiotic therapy due to BC. The continuous analysis and review of BC in a hospital allows the establishment of an adequate institutional antibiotic policy. Objective: We aim to analyze the microbial isolates in BC in an internal medicine department. Methods: Observational study of the discharged patients in a 3-month period with the analysis of the blood culture results. The information used was gathered from the clinical files. Results: There were 416 discharged patients and 478 individual blood cultures (408 aerobic; 55 anaerobic, 14 micologic, 1 micobacterial). The global positivity rate was 10.5% (50 individual blood cultures) and in 4.8% of blood cultures skin contaminants were detected. The species more frequently isolated were Escherichia coli (22.9%), Staphylococcus aureus (20.0%), Pseudomonas spp. (14.3%) and Klebsiella pneumoniae (8.6%). Among the isolates 34.3% were only susceptible to hospital used antibiotics and 25.7% were only susceptible to one community antibiotic. There were 6 agents resistant to Piperacilin + Tazobactam and no carbapenem resistant agent was found. The E. coli isolates had a high resistance rate to community antibiotics namely aminopenicillins and quinolones. Among the S. aureus, 71.4% were resistant to methicillin (MRSA) and there were no isolates of Vancomycin resistance although high levels of minimum inhibitory concentration (MIC) were detected. The Pseudomonas spp. were all susceptible to the commonly recommended antibiotics (Piperacilin + Tazobactam, Ciprofloxacin and Gentamicin). Conclusion: The positivity rate in this study is in line with published data. We highlight the reduced diversity of microbial agents identified, where 5 species account for more than 70% of all isolates and the elevated global resistance rate to aminopenicillin and cephalosporins, as well as reduced resistance to aminoglycosides, the latter may be due to less frequent use because of safety concerns. The high prevalence of MRSA is a growing concern as is the appearance of strains with high Vancomycin MIC. The high prevalence of antibiotic resistance is worrisome and has to be seriously taken into account when choosing antibiotic therapy and in the definition of hospital antibiotic policies. doi:10.1016/j.ejim.2013.08.505
ID: 647 The neutrophil index — Lymphocyte and its usefulness in the early diagnosis of infection in elderly patients. Cohort study A. Purcareaa, S. Sovailab, A. Brosc, E. Sauleaud, E. Andresa, A. Bourgarita a Internal Medicine, Diabetes and Metabolic Diseases, Strasbourg University Hospitals, Strasbourg, France b Internal Medicine, Nutrition and Endocrinology, Strasbourg University Hospitals, Strasbourg, France c Faculte de Pharmacie, Université de Strasbourg, Strasbourg, France d Medical Informatics Departement, Strasbourg University Hospitals, Strasbourg, France
The classical infectious markers, including clinical presentation and standard biomarkers, have poor sensitivity and specificity in elderly
medical care, to raise the “compliances“ and improve the living standards of HIV/AIDS patients. doi:10.1016/j.ejim.2013.08.503
ID: 515 Carbapenemase-producing Klebsiella pneumoniae (KPC) infection outbreak in Italy: Report of an experience with elderly frail patients A. Nouvennea, A. Ticinesia, N. Cerundoloa, I. Morellib, L. Guidab, B. Pratib, G. Ragnib, E. Ridoloa, L. Borghia, T. Meschia a
Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy b Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
Objectives: Carbapenemase-producing Klebsiella pneumoniae (KPC) is an emerging multidrug resistant nosocomial pathogen. It may cause epidemic outbreaks of serious systemic infections in hospital in-patients with a high degree of frailty and a large number of comorbidities. Its intrinsic resistance to almost every antibiotic therapy makes these infections particularly difficult to treat, with a documented mortality rate next to 60%. The first epidemic outbreak in Italy was described in 2009, while our hospital was involved for the first time in July 2011. The aims of this research were therefore to describe the characteristics of a KPC outbreak in a subacute critical care ward and to assess the effect of sanitary measures (bed isolation vs cohort isolation). Materials and methods: At Internal Medicine and Critical Subacute Care Unit of Parma University Hospital we consecutively studied all patients infected by KPC (133 patients, M 75, F 58, mean age 79 ± 12 years) from August 2011 to May 2012. We recorded main diagnosis, comorbidities, length of hospital stay, outcome, and anatomical district of KPC isolation for all patients. Following Emilia–Romagna Regional Guidelines, all infected patients, all contacts of these patients and all bedridden patients of the same ward were subdued to a rectal tampon for KPC detection every 7 days. From October 2011 to February 2012 we also activated a 14-bed isolation ward applying a staff cohorting management. In the previous and following period we instead applied the traditional contact isolation approach. Results: During the first two months of epidemic outbreak with the traditional contact isolation approach we observed 41 new cases (23 in the first month and 18 in the second month). The cases were limited to an average of 8 cases per month (range 3–13) in the following 5 months after the activation of the 14-bed staff cohorting ward. After the restoration of the usual contact isolation measures, we observed a new increase in incidence rates (respectively 15 and 18 cases in April and May 2012). Mean length of hospital stay of KPC-positive patients was significantly longer than that of other patients admitted to our unit (35 ± 24 vs 18 ± 12 days, p b 0.001). In most cases, KPC was isolated in rectal tampon cultures. 29 patients out of 133 (14%) deceased during hospital stay. Most of the deaths were attributable to septic shock and occurred in the first two months of the epidemic outbreak. The most prevalent comorbidities were cardiopathies (84/133 patients, 64%) and COPD (72/133 patients, 54%). Conclusions: KPC infection is quickly emerging as a relevant health issue, especially in elderly frail inpatients with multiple comorbidities. Mortality in our setting has however been lower than that described in the literature. Staff cohorting isolation measures may be effective to limit the epidemic spread, although a periodicity in KPC infections, like the one observed for other Enterobacteriaceae, cannot be excluded. doi:10.1016/j.ejim.2013.08.504
e197
ID: 576 Microbial isolates in blood cultures in an internal medicine department J. Trindade Nave, G. Nobre de Jesus, L. Santos Pinheiro, J. Meneses Santos, M. Lucas, R.M.M. Victorino Internal Medicine 2, Hospital Santa Maria, Lisboa, Portugal
Introduction: Blood cultures (BC) remain the major diagnostic test for hematogenic infections. Their results may allow the de-escalation of antibiotic therapy reducing the selective pressure on resistant bacterial strains. Studies show a positivity rate of 9–20% with 5–9% of true positives and only 0.3–1.6% of alterations in antibiotic therapy due to BC. The continuous analysis and review of BC in a hospital allows the establishment of an adequate institutional antibiotic policy. Objective: We aim to analyze the microbial isolates in BC in an internal medicine department. Methods: Observational study of the discharged patients in a 3-month period with the analysis of the blood culture results. The information used was gathered from the clinical files. Results: There were 416 discharged patients and 478 individual blood cultures (408 aerobic; 55 anaerobic, 14 micologic, 1 micobacterial). The global positivity rate was 10.5% (50 individual blood cultures) and in 4.8% of blood cultures skin contaminants were detected. The species more frequently isolated were Escherichia coli (22.9%), Staphylococcus aureus (20.0%), Pseudomonas spp. (14.3%) and Klebsiella pneumoniae (8.6%). Among the isolates 34.3% were only susceptible to hospital used antibiotics and 25.7% were only susceptible to one community antibiotic. There were 6 agents resistant to Piperacilin + Tazobactam and no carbapenem resistant agent was found. The E. coli isolates had a high resistance rate to community antibiotics namely aminopenicillins and quinolones. Among the S. aureus, 71.4% were resistant to methicillin (MRSA) and there were no isolates of Vancomycin resistance although high levels of minimum inhibitory concentration (MIC) were detected. The Pseudomonas spp. were all susceptible to the commonly recommended antibiotics (Piperacilin + Tazobactam, Ciprofloxacin and Gentamicin). Conclusion: The positivity rate in this study is in line with published data. We highlight the reduced diversity of microbial agents identified, where 5 species account for more than 70% of all isolates and the elevated global resistance rate to aminopenicillin and cephalosporins, as well as reduced resistance to aminoglycosides, the latter may be due to less frequent use because of safety concerns. The high prevalence of MRSA is a growing concern as is the appearance of strains with high Vancomycin MIC. The high prevalence of antibiotic resistance is worrisome and has to be seriously taken into account when choosing antibiotic therapy and in the definition of hospital antibiotic policies. doi:10.1016/j.ejim.2013.08.505
ID: 647 The neutrophil index — Lymphocyte and its usefulness in the early diagnosis of infection in elderly patients. Cohort study A. Purcareaa, S. Sovailab, A. Brosc, E. Sauleaud, E. Andresa, A. Bourgarita a Internal Medicine, Diabetes and Metabolic Diseases, Strasbourg University Hospitals, Strasbourg, France b Internal Medicine, Nutrition and Endocrinology, Strasbourg University Hospitals, Strasbourg, France c Faculte de Pharmacie, Université de Strasbourg, Strasbourg, France d Medical Informatics Departement, Strasbourg University Hospitals, Strasbourg, France
The classical infectious markers, including clinical presentation and standard biomarkers, have poor sensitivity and specificity in elderly