REVIEW. Hospital, Shrewsbury, Shropshire and 2 Shropshire and Staffordshire Health Protection Unit, Health Protection Agency, UK

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1 REVIEW Control of infections due to extended-spectrum b-lactamase-producing organisms in hospitals and the community R. E. Warren 1, G. Harvey 1, R. Carr 2, D. Ward 2 and A. Doroshenko 2 1 Department of Microbiology, Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, Shropshire and 2 Shropshire and Staffordshire Health Protection Unit, Health Protection Agency, UK ABSTRACT Control of infection classically involves hand and healthcare hygiene, reduction of selective and ineffective chemotherapy, reduction of invasive procedures and achlorhydria and adequate staffing, along with appropriate containment and concentration of patients. Investigation and control of any continuing sources of infection in food and water supplies is important also, as is recognition of individuals carrying high-risk strains and species. The onset of infection may be distant from the time of acquisition and may critically affect epidemiological assessment of control points. Carriage may be prolonged, increasing the likelihood of recurrent infection and exacerbating the difficulty of control. Mortality associated with resistance is difficult to assess retrospectively and may not be high, complicating analysis of the success or failure of control measures. Keywords Carriage, control, E. coli, extended-spectrum b-lactamases, review, urinary infection Clin Microbiol Infect 28; 1 (Suppl. 1): INTRODUCTION Organisms producing extended-spectrum b-lactamases (ESBLs) that developed as variants of the TEM-1, TEM-2 and SHV-1 enzymes have caused many local and national outbreaks, mostly within specialised hospital units. Control has been difficult in proportion to the size of the outbreak, with treatment for severe infections usually requiring carbapenems. The recent, widespread emergence of multiresistant strains of Escherichia coli with CTX-M ESBLs and various pathogenicity factors has further complicated control and creates an acute and important international issue.[1] Resistance in E. coli is important because the organism is the commonest Gram-negative pathogen, is widespread among populations, and is important in healthcare settings other than hospitals. Although resistances vary by country and strain, many of the E. coli strains with CTX-M ESBLs are also resistant to b-lactam inhibitor combinations, Corresponding author and reprint requests: R. E. Warren, Department of Microbiology, Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, Shropshire SY3 8XQ, UK Rod.Warren@sath.nhs.uk quinolones, trimethoprim, tetracycline, aminoglycosides and chloramphenicol, leaving few options for treatment, apart from carbapenems, cephamycins, fosfomycin (which is not marketed in the UK), colistin, nitrofurantoin and, possibly, tigecycline. SMALL AND LARGE OUTBREAKS OF ESBL-PRODUCINGORGANISMS Small hospital outbreaks of organisms producing TEM and SHV ESBLs are frequent, and are often due to single clones [2]. Transmission of ESBL (or even AMPC or carbapenemase)-encoding plasmids within, and between, species may also occur [3,]. These small outbreaks are often centred on particular environments such as intensive care units [], haemato-oncology units [], urology units [7], units for care of the elderly, wards for long-stay gastrointestinal surgical patients, transplantation units and neonatal units. The site of infection relates to the particular environment and the type of patient (with, e.g., ventilatorassociated pneumonia in intensive care unit patients, or bacteraemia of gut origin in neutropenic patients). Prior to the CTX-M era, termination of outbreaks due to resistant bacteria often involved

2 Warren et al. Infection control vs. ESBL producers 12 the adoption of a hitherto unused antibiotic class. Historical examples can be found at the times of the successive introductions of trimethoprim, cephalosporins or quinolones. These agents are potent in modifying the gut flora, reducing carriage of epidemic resistance. Multiresistance, and the fact that no new anti-gram-negative antibiotic classes are available, complicate the control of CTX-M-producing strains. PRINCIPLES OF CONTROL Classic principles for controlling multiresistant Gram-negative strains include reducing selection pressure by avoiding all agents to which the strain or plasmid donor organisms are resistant in the carriage site, which is principally the gut in the case of E. coli [8]. Gut carriage of resistant E. coli strains has long been recognised as a riskfactor for resistant urinary tract infection (UTI), although these vary in virulence [9]. For ESBL producers, not only cephalosporins [1] but also other antibiotics [] must be considered as selectors. The gut concentration of active antibiotic is important here (and for selection of Clostridium difficile) and may be high if there is residual unabsorbed drug from oral agents or biliary excretion combined with potency insufficient to be overcome by gut dilution. By contrast, drugs active against ESBL producers may reduce the chance of carriage [11]. The susceptibility of some ESBL producers to parenteral aminoglycosides is important, as these now infrequently used agents seldom reach selective gut concentrations and so may diminish selective pressures. More generally, when considering which non-selective agents to use, it should be noted that collateral damage is not confined to Gram-negative species in the gut but extends to Gram-positive species at other body sites [12]. For example, selection of methicillin-resistant Staphylococcus aureus and enterococci is associated with use of quinolones and cephalosporins. Classic control also emphasises minimising the frequency of procedures that carry a risk of promoting infection from colonisation. Urinary catheterisation [13], endotracheal or nasogastric intubations, gut surgery and induction of achlorhydria all increase the risk of infection by transferring Gram-negative organisms from colonisation to infection sites. Antibiotic prophylaxis for invasive procedures in those colonised with ESBL producer organisms should be tailored against the colonising strain. Ensuring adequate hand hygiene and staff patient ratios minimises the risk of inter-patient spread of resistant strains. Admission from other hospitals or from residential care should generate automatic alerts to detect readmitted patients previously found to carry multiresistant ESBL producers. Staff in the transferring units should notify the receiving infection control staff of such transfers. Single-room accommodation, or cohort isolation, for both current and past cases, may improve care and diminish the chances of spread. Cohort wards are inflexible because of their fixed bed complement and the irreducible minimum of staff required. Minimising the length of stay of patients carrying an outbreak strain by early discharge also reduces the chances of such patients acting as sources of cross-infection or cross-colonisation. UK EXPERIENCE IN CONTROLLING SPREAD OF E. COLI WITH CTX-M ESBLS The UK is affected by both diverse and clonally related E. coli strains with CTX-M-1 (and rarely other) ESBLs [1]. Infections due to these ESBLs often become manifest in the community, where there are no licensed oral agents suitable for use if they cause an upper UTI. Older patients, not the population with cystitis, are particularly involved. The problem was recognised in two Shropshire hospitals and their associated primary-care communities in April 23, but retrospectively was identified as having started in January, with earlier cases in the West Midland region dating back to 22 [1]. The problem involved four of five related serotype O:2 clade B2 strains with CTX-M-1 ESBLs, that were simultaneously appearing elsewhere in the UK, e.g. Belfast ( MonthlyReports/Volume_13_2/DecNo1.pdf) and Southampton ( Download/Public/192/1/cmoreport2.pdf. 73). Outbreaks in these places had an identical time course. This suggested a common-source outbreak, although no source was identified, and analysis is complicated because the O2 gene can be transferred among strains [1], and also because the different clone occurred in different proportions at different sites, with A, B, D and E in Shropshire,

3 12 Clinical Microbiology and Infection, Volume 1, Supplement 1, January 28 but A alone in Southampton, and A and C in Belfast. A further complication is that not all hospitals were ideally identifying ESBL producers, or even identifying urinary isolates to species level. This oligoclonal problem was not universal, as CTX-M-1-producing E. coli emerged to become a problem in the UK in 23, and diverse CTX-M- 1-producing strains were detected simultaneously, without obvious clonality in other parts of the country [17]. It is notable that E. coli strains with CTX-M enzymes were clonal in Canada [18], France [19,2] and Israel [21], but not in Spain [22] or Italy [23], and, in some settings, plasmid spread among E. coli strains, or recombination of elements from the plasmids, may be critical in the rapid appearance of CTX-M-1-producing strains, more so than the slower person-to-person spread of clones, gradually emerging above detection limits. However, this is speculative, and the plasmids or transposable elements present in the heterogeneous CTX-M-1-positive UK strains [17] remain unknown. All these differences in behaviour, clonality and plasmid transmissibility are likely to affect responses to control measures, and may vary in the UK context between different components of the O2 clone and unrelated strains that are further modulated by differences in their virulence factors [2] and antibiotic resistance profiles. Overall, the present diversity and dynamics of strains and self-transmissible plasmids imply that the problem can only be controlled, not eliminated. during October December 23: 87% were female (mean age 72 years); % had been catheterised in the last 3 years; and 9% had been hospital outpatients or inpatients in the preceding 3 years. Prior antibiotic use had not been heavy: 7% had received an antibiotic in the last 3 years but, on average, each patient had only received a single course each year. Diet, routine food purchase, drinking from private water supplies and animal contact did not suggest a source. A further survey, through general practitioners, of 73 contactable patients was conducted during April June 2. Of these patients, % had been in hospital, 18% were in residential healthcare outside hospital, and 3% had been treated with antibiotics in the 3-year period preceding infection with the ESBL producers. Only 7% had chronic indwelling urinary catheters. Not surprisingly, 82% initially were treated empirically with antibiotics to which the strain was resistant. The integration of these data with a hypothesis of a common source outbreak is difficult, unless it is assumed that food sources led to faecal colonisation as an antecedent to UTI. New clinical infections in non-hospital residential healthcare facilities led to employment in Shropshire of a full-time nurse-educator to upgrade nursing hygiene and practice, with particular attention to catheter care, including unbroken drainage and bag care, and ensuring that wash-bowls were not shared. Nursing homes from which patients with ESBL producers were admitted, or to which they were discharged, were prioritised for inspection. Descriptive epidemiology and control In the period 23 2 in Shropshire, 8% of a total of 27 infections due to E. coli strains with CTX-M-1 ESBLs involved the urinary tract, comprising, overall, 3.% of hospital and 1.% of community UTIs and, respectively, 8.% and 3.% of second and subsequent UTIs. Forty-seven per cent were diagnosed in primary care settings but only 2% had no history of admission to local hospitals or residential care homes. Descriptive epidemiology was applied to assess potential sources and control points for ESBL E. coli. Aside from contact with hospitals, these early surveys suggested catheterisation and antibiotic use as controllable risk-factors. Sixteen patients with infections with gentamicin-susceptible strains (dominantly Group A) were interviewed Antibiotic policy change To reduce selection for these ESBL-producing E. coli strains, changes were made to antibiotic policy at the Shropshire hospitals. First, attempts were made to reduce cephalosporin use. Use in UTI was discouraged, and they were only advocated in cases of the severest pneumonia, but not in cases of chronic obstructive pulmonary disease. Second, less successful attempts were made to reduce quinolone use. Quinolones other than ciprofloxacin and norfloxacin had never been used in the hospitals for respiratory infection, and an attempt was made to reduce the empirical use of these agents, except in cases of neutropenia and cirrhosis. Third, ertapenem, or occasionally imipenem, was used empirically for suspected Gram-negative sepsis of community origin, and

4 Warren et al. Infection control vs. ESBL producers 127 for sepsis in all patients with a past history of sepsis due to ESBL producers. Imipenem was used in hospital-acquired Gram-negative sepsis and as the initial empirical choice in cases of ventilator-associated pneumonia. Cephalosporin use was discontinued for prophylaxis and treatment in gut surgery, and gentamicin (active against the prevalent local (Group A) CTX-M-1- producing E. coli strain) was used as appropriate, in combination with benzylpenicillin and metronidazole; imipenem or ertapenem was substituted in patients with renal impairment. b-lactam inhibitor combinations were neither reported nor routinely encouraged, since most ESBL producers were resistant to piperacillin tazobactam. Coamoxiclav use was restricted to gynaecology obstetrical, ear, nose and throat and paediatric infections, where ESBL producers remained rare. The effects of these changes on antibiotic use in the Royal Shrewsbury and Princess Royal Hospital, Telford, in this period are shown in Fig. 1. From April 2, changes were made to all laboratory antibiotic reporting including for physicians in primary care to influence prescribing. Quinolone reporting, hitherto unrestricted for urinary infection, was restricted to Gram-negative isolates resistant to amoxycillin and trimetho- (a) 2 Antibiotic usage at Shrewsbury hospital DDD / 1 patient days DDD/ bed day: Amoxicillin 22-3 Q1 3- Q2 3- Q3 3- Q 3- Q1 - Q2 - Q3 - Time Q - Q1 - Q2 - Q3 - Nitrofurantoin Trimethoprim Co-amoxiclav Gentamicin Q - Amoxicillin Quinolones Cephalosporins Carbapenems Q1 - Q2-7 7 (b) 2 Antibiotic usage at Telford hospital DDD/1 patient days: other agents DDD/1 patient days:amoxicillin Fig. 1. Selected antibiotic use at (a) Shrewsbury hospital and (b) Telford hospital. Yr 2-3 Q1 3- Q2 3- Q3 3- Q 3- Q1 - Q2 - Q3 - Q - Q1 - Q2 - Q3 - Q - Q1 - Q2 - Q Nitro Trimeth Co-amoxiclav Gent Amox Cephalosporins Carbapenems Quinolones

5 128 Clinical Microbiology and Infection, Volume 1, Supplement 1, January 28 prim. Suppression of cephalosporin reporting continued, whereas routine reporting of nitrofurantoin was introduced. However, it was difficult to ensure that junior doctors did not prescribe nitrofurantoin for upper UTI, and treatment failures were seen with nitrofurantoin-susceptible organisms, consistent with a rate of asymptomatic upper UTI of 1%. Recurrences and a modest % increase in resistance were noted with nitrofurantoin during the study period. This agent is completely absorbed and does not affect the gut flora. Occasional patients were treated on the basis of combination disk tests with oral cefpodoxime in combination with amoxycillin clavulanate, without adverse effects. These antibiotic policy changes had no effect, over 3 months, on the incidence of cases (Fig. 2). Concentration of patients We initially attempted to place patients known to be infected or colonised with ESBL-producing E. coli in single rooms, without apparent effect on the incidence and spread to more than wards in two general and five smaller hospitals in Shropshire. In September 2, a cohort isolation ward was introduced for all patients diagnosed with, or known to have been infected or colonised in the past with ESBL-producing E. coli. Contemporaneous control of the gentamicin-resistant (a) New cases gentamicin S / month Antibiotic policy changed Isolation ward open (b) Month/Year Telford hospital Shrewsbury hospital Oswestry hospital Telford GPs Shrewsbury GPs Powys GPs Powys community hospitals Shropshire community hospitals Antibiotic policy changed New cases gentamicin R / month Month/year Isolation ward open Telford hospital Shrewsbury hospital Oswestry hospital Telford GPs Shrewsbury GPs Powys GPs Powys community hospitals Shropshire community hospitals Fig. 2. Incidence in primary care and (a) Shrewsbury and (b) Telford hospitals of new gentamicin-susceptible and -resistant cases in relation to antibiotic policy, reporting changes and opening of cohort isolation ward.

6 Warren et al. Infection control vs. ESBL producers 129 ESBL-producing strain and decreased incidence of gentamicin-susceptible ESBL-producing isolates occurred (Fig. 2) in both hospitals and in the primary-care populations. Prolonged pre- and post-infection faecal carriage. It is uncertain whether faecal carriage is a riskfactor for spread of infection, but this seems plausible, given that some of the aged, dependent individuals involved had problems with continence. Faeces were directly plated on cystine lactose electrolyte depleted agar incorporating ciprofloxacin (1 mg L), with a cefpodoxime disk (1 lg) placed on the inoculum site. Resistant isolates were confirmed as ESBL-producing E. coli using chromogenic urinary agar (BBL) and IsoSensitest agar with cefpodoxime disks with and without clavulanate. This screening demonstrated the wide prevalence of ESBL-producing E. coli, the frequent subsequent development of UTI, and differences among producer strains. From September to December 23, the isolation rate was 2.3% for 7 faeces submitted from the community for the investigation of bowel symptoms, as compared with.2% for faeces from those in hospital. From April 23 to October 2, rectal swabs or faeces were sought on admission to hospital from all patients who had been hospitalised or in a residential healthcare environment in the preceding 8 weeks and from all patients with a past history of infection or colonisation with ESBLproducing E. coli. In total, 293 patients were sampled, but compliance with the request was poor, probably less than 2%. The patients were then followed for clinical infection for a minimum 7-month period. Excluding those patients (.2% of the total) examined because they had a previous infection with ESBL-producing E. coli, the asymptomatic carriage rate in this hospitalised population was 2.7%. Gentamicin-resistant (Groups B,D,E) and -susceptible (Group A) strains behaved differently. The resistant strain was found in 23% of clinical infections, but faecal carriage prior to infection was seen in only two patients (.1% of total faeces), whereas 11 carriers had no preceding or subsequent infection. The ratio of carriage converting to infection was therefore 13:2. The gentamicin-susceptible strain accounted for 77% of clinical infections, and in 29 patients (1.39% of all faeces) faecal carriage was detected prior to infection, whereas there was no preceding or subsequent infection in carriers. The ratio of carriage converting to infection was therefore much higher for this strain, at 7:29. This strain-dependent difference in conversion to infection is statistically significant, but it is not clear whether it is associated with virulence factors. The occurrence of aggregative adherence factors in the gentamicinsusceptible strain A is noteworthy: diffuse enteroadherence virulence factors of the dfr class are known to be associated with recurrent urinary infection and chronic renal infection, with the yersiniabactin and aerobactin siderophore and with clade B2 [2]. Clinical infections with ESBL-producing organisms frequently recur, but the period for which control measures should be applied to individuals is unclear. The time elapsed between isolation of ESBL-producing E. coli from faeces both before and after first infection with these strains is shown in Fig. 3. Twenty per cent of the patients were carriers, before and after infection, for more than 1 year. Although 7% of patients presented with community-diagnosed infection, only 2% had no history of hospitalisation or contact with residential homes. Therefore, as with Klebsiella [2], acquisition of the organism can be distant from the time when the patient develops, and is diagnosed with, an infection. Finally, it should be added that there are many uncertain UTIs diagnosed in the community that may follow organism addition to the faecal flora in the hospital but, alternatively, infection in the hospital may evolve from colonisation acquired in the community. Moreover, we lack comprehensive records of catheterisation, so cannot assess whether catheterisation was temporally associated with subsequent onset of infection. Common sources of colonisation and infection: the food chain Consideration was given to the critical possibility that ESBL-producing E. coli might be spreading via the food supply perhaps on a national rather than a hospital scale, given the dispersed distribution of the clonally related serotype O2 strain in the UK. No clues were offered by dietary or food origin history but, retrospectively, this is not surprising, given the prolonged carriage periods

7 13 Clinical Microbiology and Infection, Volume 1, Supplement 1, January 28 (a) 1% 9% 8% % Patients with positive faeces by days post diagnosis of infection Gen S (n = 1) GenR (n = 1) 7% % % % 3% 2% 1% % (b) 1% 9% 8% Days/months elapsed m % Faeces positive with GenS ESBL days/months pre infection 1+ to 18m 21+ to 2m Gen S (n = 29) NB Gen R (n = 2) 7% % % % 3% % Days/months elapsed 9 12m 1+ to 18m 21+ to 2m 2% 1% Fig. 3. Maximum intervals between detection of faecal carriage and urinary infection. prior to infection revealed in faecal colonisation studies, and the admixture of hospital admissions included in our initial study. There are now several papers describing the presence of ESBLproducing E. coli [27 31] in raw chicken and meat, and also the presence of extra-intestinal pathogenic quinolone-resistant E. coli [32 3], including O2 strains. [3] There are, as yet, no such reports for ready-to-eat food. Although isolation of organisms in raw food, which is to be cooked, would not normally be regarded as a hazard for urinary E. coli infection, it is regarded as a hazard for enteropathogens, and the hazard might be real if raw meat contains uropathogenic E. coli, and if the raw meat and ready-to-eat foods are mixed in the catering environment. Reassurance on the separation of raw and cooked products as part of HACCP control was obtained by inspection of our two hospital kitchens. A 2 survey of raw chicken breast fillets bought at local supermarkets did not reveal E. coli with CTX-M-1 or any other CTX-M

8 Warren et al. Infection control vs. ESBL producers 131 type in British-produced chicken. However, other CTX-M enzymes were present in raw chicken, partially of overseas origin. Such local surveys do not exclude the possibility that the problem with E. coli with CTX-M-1 ESBL originated from foodstuffs that were only briefly available, with subsequent transmission being human oro faecal. Control of mortality An early issue with any new antibiotic resistance is to control any increase in mortality due to treatment failures. Any such increase may vary with the site of infection and the choice of empirical chemotherapy. Appropriate therapy, once susceptibility data are available, is theoretically easy to ensure. In Shropshire, 2 patients with 7 bacteraemias due to ESBL-producing E. coli, out of 3 infections, were seen in a 3-year period. In 3 cases, the blood culture isolate was the first ESBL-producing isolate obtained from the patient. Ertapenem and imipenem became the empirical therapy of choice for bacteraemia seen on medical units, limiting the use of non-active therapy. Among the patients with bacteraemia with ESBL producers who died, only 9 19 did so within 1 days (%). This compares with 189 deaths among 73 bacteraemias due to ESBLnegative E. coli in 39 patients in the same time period, in the same institution. Sixty-two (33%) of these patients died within 1 days, suggesting only a slight excess of associated mortality for the ESBL producers. Mortality in less severe infections, such as UTI, has usually been reported to be low, but in this ESBL outbreak was externally reported as high [3]. Retrospectively matching controls for underlying condition is difficult, but an unreported local, retrospective, 28-day mortality cohort study during 22 2 of 188 patients with ESBLproducing E. coli was undertaken. This excluded any patient who developed a bacteraemia, was matched with controls by 1-year age bands, and location in primary or secondary care. Matching by morbidity and underlying condition was not attempted. Four control groups were used: (i) patients with trimethoprim-, amoxycillin-, cephalosporin-, nitrofurantoin- and quinolonesusceptible strains (n = 39); (ii) patients with isolated trimethoprim resistance (n = 38); and (iii iv) two more poorly matched groups comprising all patients with quinolone-resistant strains (n = 28). Mortality was significantly higher in cases with ESBL producers (2.7%) than in all controls (p <.), with odds ratios of approximately 2, except for the quinolone-resistant controls. Adjustments for inpatient stay eliminated any significant difference between the cases and those with strains resistant to quinolones, but not producing ESBLs. CONCLUSION As a first priority, antibiotic use must be made appropriate and patient outcomes confirmed to be satisfactory, both initially and continuously, for all infections. It is essential to integrate laboratories for hospitals and their local communities and to clearly delineate the epidemiology of resistant strains and their acquisitions. In the case of ESBLproducing E. coli, common sources in the food chain should be investigated comprehensively, systematically and, if necessary, on an international scale. Their termination is probably critically important. Attention must be paid to the risks in environments where the strain occurs, aiming to decrease those practices that facilitate infection or colonisation. This extends to spread in residential non-hospital healthcare environments, which can be an important source of reintroduction to hospitals. Hospital admissions from potential sources in other healthcare environments, therefore, should be screened and computer alerts used to admit those previously found positive for carriage, so that containment isolation can be undertaken. The use of cohort concentration to restrict the risk of cross-infection, and to speed appropriate treatment and discharge, should be considered, especially if there are insufficient single rooms. The extent and duration of asymptomatic carriage and associated risk of recurrence and spread will influence the use of such accommodation. The level at which control becomes impossible is a value judgement, but rising incidence is important, given the dearth of new oral agents for the treatment of infection due to Gram-negative bacteria. ACKNOWLEDGEMENTS We wish to acknowledge the role of many members of staff in the described Shropshire experience, particularly P. O Neill (Consultant Microbiologist), K. Howells, D. Patel (Technical

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