Incidence of CLABSI CRE Found to Be Higher in Long-Term Acute Care Hospitals

*Updated on 4/27/2018 at 12:24 PM EST

The growing threat of antibiotic resistance and its repercussions has become a serious public health concern as the world continues to run out of antibiotics that are effective against these ever-changing pathogens.

Particularly troubling is a group of gram-negative bacteria referred to as carbapenem-resistant Enterobacteriaceae (CRE), which are associated with high morbidity and mortality, as they have proven highly resistant to most available antibiotics. In fact, some studies have found that CRE bacterial infections have a mortality rate as high as 50%. These bacteria are known to rapidly spread among patients in health care settings, and, as such, they are known to have been responsible for several deadly outbreaks in hospitals.

One of the ways in which these bacteria are known to attack is through central lines. In a recent analysis, investigators compared central line-associated bloodstream infections (CLABSIs) attributed to CRE in short-term acute care- (ACHs) with CLABSIs in long-term acute care hospitals (LTACHs) using pathogen and susceptibility data reported to the National Healthcare Safety Network (NHSN) from 2015 to 2016. They presented their findings at the SHEA Spring 2018 Conference.

"Most reported analyses of CRE patterns have looked at short-stay healthcare settings, mainly acute care hospitals (ACHs) and critical access hospitals (CAHs)," Allan K. Nkwata, MPH, Centers for Disease Control and Prevention, told Contagion^®. "Fewer analyses have been reported on CRE patterns in other healthcare settings such as long-term acute care hospitals (LTACHs)."

CRE was defined as any Klebsiella pneumoniae, Klebsiella oxytoca, Escherichia coli or Enterobacter spp that tested resistant to imipenem, meropenem, doripenem or ertapenem, according to the authors. Susceptibility results were then reported to the NHSN as any of the following: susceptible, intermediate, resistant, or not tested.

For each pathogen by facility type, the investigators calculated a pooled mean percentage of resistant pathogens by dividing the sum of pathogens that tested resistant by the sum of pathogens tested.

The results showed that a total of 13,996 CLABSIs associated with the aforementioned pathogens were reported to the NHSN from both ACHs and LTACHs. The most prevalent CLABSI-causing pathogen was Klebsiella spp, which was responsible for 6172 infections (44% of all infections).

When looking specifically at ACHs, the investigators found that in 2015, 6438 CLABSIs were reported, whereas slightly less were reported in the following year (6113); however, 77% of all isolates were tested for carbapenem resistance (CR), and the investigators found that the overall resistance percentage increased from 4.7% in 2015 to 5.3% in 2016. Specifically, CR increased by 0.2%, 0.8%, and 1.0% in E. coli, Enterobacter, and Klebsiella spp, respectively.

A total of 787 CLABSIs were reported in 2015 in LTACHs; again, slightly less (658) were reported the following year. The authors report that about 88% of the isolates were tested, and the overall resistance percentage in LTACHs appeared to be much higher compared with ACHs. However, the resistance percentage decreased from 18.5% in 2015 to 15.8% in 2016; whereas CR increased in Enterobacter by 3.7%, CR decreased in E. coli and Klebsiella by 3.2% and 2.4%, respectively.

Despite the noted decrease, more CLABSI CRE were found in LTACHs compared with ACHs. The authors attributed the decline to improvements made in infection control policies and interventions among patients and staff. These interventions include CRE screening, contact precautions, as well as chlorhexidine baths.

"We did not find it surprising that more CLABSI CRE were found in LTACHs than ACHs, as this was observed in a previous report," Dr. Nkwata explained to Contagion^®. "However, we encourage cautious interpretation of our findings, as we reported proportions and not absolute counts. This is because the smaller percentages in ACHs still exceed by a large margin the raw numbers represented by percentages in LTACHs." Therefore, more data collected over a longer period of time from LTACHs would be needed, so that investigators can perform additional statistical tests for comparison.

In the meantime, Dr. Nkwata provided the 3 major strategies that providers working in LTACHs stive to do in order to curb the spread of resistant infections. They are as follows:

1. Prevent the infections to begin with.
2. If infections or colonization with resistant bacteria occur, prevent the spread of pathogens in health care facilities
3. Use antibiotics more judiciously, which is the primary goal of antibiotic stewardship programs

"LTACH staff should remain vigilant around the use of contact precautions for both patients and healthcare providers suspected of any CRE-associated infection," he concluded.