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Is ESBL a Hospital or Community Problem?

What is an ESBL producer?

Extended-Spectrum Beta-Lactamase (ESBL) are enzymes that inactive and confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam, and which are inhibited by Clavulanic acid. They are found exclusively in gram-negative organisms, primarily Klebsiella Pneumoniae, Klebsiella oxytoca, and Escherichia coli.

 

How does ESBL spread?

The ways that ESBL can spread include:

  1. Someone who colonized or infected with ESBL touches you with unwashed hands.
  2. You touch objects or surfaces that have the germs.
  3. Healthcare workers touch you without washing their hands properly after contact with an infected patient, object, or surface.

ESBL can enter your body in the following ways:

  1. Through the mouth. This happens if you have the germs on your hands and then touch your mouth, such as when you eat. The germs are then swallowed and live in your intestine.
  2. Through the urinary tract. This occurs if you already have ESBL in your bowel and do not cleanse properly after a bowel movement. ESBL can also enter the urinary tract through a urinary catheter if you have one.
  3. Through a wound.

Hospital-acquired ESBL producers

Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common types are bloodstream infection (BSI), pneumonia (e.g., ventilator-associated pneumonia [VAP], urinary tract infection [UTI], and surgical site infection [SSI])

Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae has been reported worldwide. More than 50 hospital outbreak with ESBL producers (affecting 3000 patients) has been published worldwide in which methods were used to ascertain the genotypic relatedness of strains. In every reported outbreak, the common strain was isolated from more than two patients.

Prevalence rates vary from hospital to hospital and from country to country following:

  1. A study in Japan reported that among ESBL-positive E. coli strains, 94% of the isolates carried blaCTX-M, but none carried blaTEMandblaSHV, indicating that blaCTX-M in clinical settings might have originated from animal foods1. However, demonstrated that among ESBL gene- positive E. coli, blaCTX-M -9(67%) was most prevalent followed by blaCTX-M-1 (19%) and blaCTX-M-2 (5.8%) genes in outpatients11.
  2. In a sample of 5739 isolates from 72 US hospitals collected in 2012, the overall frequency of ESBLs was 16 percent in pneumonia, 11.9 percent in E. coli, 10 percent in K. oxytoca, and 4.8 percent in P. mirabilis9. CTX-M-15 was the most common ESBL identified, followed by SHV- and TEM-type enzymes. Two or more β-lactamase genes were identified in 63 percent of the isolates, including non-ESBLs and carbapenemases.
  3. Rates of ESBLs have also been increasing in the US, as reflected by a study that reported an increase in the incidence of ESBL-producing infections in southeastern US hospitals from 11.1 to 22.1 infections per 100,000 patient days between 2009 and 20149.
  4. ESBL prevalence is even higher in isolates from Asia, Latin America, and the Middle East3, reaching 60 percent in pneumonia isolates from Argentina, and 48 percent in E. coli isolates from Mexico4,2.
  5. Increasing community-acquired ESBL infections led to the discovery of concomitant high and increasing rates of fecal colonization by ESBL-producing bacteria worldwide5,10.
  6. A total of 34 isolates from 27 patients (6.1%) admitted to Dutch hospitals were ESBL/pAmpC positive and 29 ESBL- E. coli, three pAmpC-E. coli, one ESBL-Enterobacter cloacae, and one pAmpC-Proteus mirabilis were found. In the German hospital, 18 isolates (16 E. coli and 2 Klebsiella pneumoniae) from 17 patients (7.7%) were ESBL positive. In isolates from the hospitalized patients, CTX-M-15 was the most frequently detected ESBL-gene. In the Dutch community, 11 individuals (2.75%) were ESBL/pAmpC positive: 10 ESBLE. coli (CTX-M-1 being the most prevalent gene) and one pAmpC E. coli. Six Dutch (1.3%) and four German (3.9%) hospitalized patients were colonized with VRE. Genetic relatedness by core genome multi-locus sequence typing (cgMLST) was found between two ESBL-E. coli isolates from Dutch and German cross-border hospitals and between VRE isolates from different hospitals within the same region11.
  7. In the study period, 49 patients needed hospitalization for upper UTI. Overall, in 25 patients (51%), cultures were negative. In the remaining, seven patients (14.3%) presented positive blood and urine-culture for ESBL-E. coli. Of these, four were female, and three were male. Their median age was 73 years (range 66-84). The median hospital stay of these patients was 23 days (range 13 to 45 days)7.

 

How can hospital control spread?

Many hospitals and long-term care facilities take steps to help prevent ESBL:

  1. Handwashing. This is the most critical way to help prevent the spread of germs. Healthcare workers wash their hands with soap and water or use an alcohol-based hand cleanser before and after treating each patient. They also clean their hands after touching any surface that may be contaminated with germs.
  2. Protective clothing. Healthcare workers and visitors will likely wear gloves and a gown when entering the room of a patient with ESBL. Before leaving the room, they remove these items and clean their hands.
  3. Private rooms. Patients with ESBL are put in private rooms or in a room with another patient who also has ESBL.
  4. Personal care items. Patients with ESBL may have their patient care items, such as thermometers and stethoscopes. If these items are shared, they are thoroughly cleaned and disinfected before reuse.
  5. Monitoring. Hospitals and long-term facilities monitor the presence and spread of ESBL. They teach caregivers the best ways to prevent it.

 

 

Reference:

  1. Hara, T., Sato, T., Horiyama, T., Kanazawa, S., Yamaguchi, T. and Maki, H. 2015. Prevalence and molecular characterization of CTX-M extended-spectrum β-lactamase-producing Escherichia coli from 2000 to 2010 in Japan. J. Antibiot. 68: 75–84.
  2. Gales AC, Castanheira M, Jones RN, Sader HS. Antimicrobial resistance among Gram-negative bacilli isolated from Latin America: results from SENTRY Antimicrobial Surveillance Program (Latin America, 2008-2010). Diagn Microbiol Infect Dis 2012; 73:354.
  3. Morrissey I, Hackel M, Badal R, et al. A Review of Ten Years of the Study for Monitoring Antimicrobial Resistance Trends (SMART) from 2002 to 2011. Pharmaceuticals (Basel) 2013; 6:1335.
  4. Sader HS, Farrell DJ, Flamm RK, Jones RN. Antimicrobial susceptibility of Gram-negative organisms isolated from patients hospitalized with pneumonia in US and European hospitals: results from the SENTRY Antimicrobial Surveillance Program, 2009-2012. Int J Antimicrob Agents 2014; 43:328.
  5. Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal carriage of extended-spectrum β-lactamases in the community: toward the globalization of CTX-M. Clin Microbiol Rev 2013; 26:744.
  6. Chong, Y., Shimoda, S., Yakushiji, H., Ito, Y., Miyamoto, T., Kamimura, T., Shimono, N. and Akashi, K. 2013. Community spread of extended- spectrum β-lactamase-producing Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis: a long-term study in Japan. Med. Microbiol. 62: 1038–1043
  7. Picozzi SCM., Casellato S., Carmignani L. Extended-Spectrum Beta-Lactamase-Positive Escherichia coli Causing Complicated Upper Urinary Tract Infection: Urologist Should Act in Time. Urol Ann. 2014 Apr-Jun; 6(2): 107–112.
  8. Castanheira M, Farrell SE, Krause KM, et al. Contemporary diversity of β-lactamases among Enterobacteriaceae in the nine U.S. census regions and ceftazidime-avibactam activity tested against isolates producing the most prevalent β-lactamase groups. Antimicrob Agents Chemother 2014; 58:833.
  9. Thaden JT, Fowler VG, Sexton DJ, Anderson DJ. Increasing Incidence of Extended-Spectrum β-Lactamase-Producing Escherichia coli in Community Hospitals throughout the Southeastern United States. Infect Control Hosp Epidemiol 2016; 37:49.
  10. Karanika S, Karantanos T, Arvanitis M, et al. Fecal Colonization With Extended-spectrum Beta-lactamase-Producing Enterobacteriaceae and Risk Factors Among Healthy Individuals: A Systematic Review and Meta-analysis. Clin Infect Dis 2016; 63:310.
  11. Zhou X., Cobos SG., Ruijis GJM. Epidemiology of Extended-Spectrum b-Lactamase-Producing E. coli and Vancomycin-Resistant Enterococci in the Northern Dutch-German Cross-Border Region. Frontiers in Microbiology. Oktober 2017, Vol. 8, 01914

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