Occurrence of Healthcare-Associated Infections (HAIs) by Escherichia coli and Klebsiella spp. Producing Extended-Spectrum β-lactamases (ESBL) and/or Carbapenemases in Portuguese Long-Term Care Facilities

Abstract

Extended-spectrum-β-lactamase (ESBL)- and carbapenemase-producing bacteria are widespread in hospitals, but the extent of this problem in long-term care facilities (LTCFs) is poorly understood. We aimed to elucidate, in the Portuguese regional clinical context, the relevance of LTCFs as a reservoir of Escherichia coli and Klebsiella spp. producing ESBL- and/or carbapenemases (Ec/Kp-ESBL/CARB). Fourteen LTCFs from Portugal, corresponding to units of convalescence (UC/n = 3), medium-term internment and rehabilitation (UMDR/ n = 5), or long-term internment and maintenance (ULDM/n = 6), were analyzed (2016-2019). All patients with Ec/Kp-ESBL/CARB infections acquired during LTCF stay were included, and detailed information was collected. Prevalence of patients with healthcare-associated infections (HAIs) by Ec/Kp-ESBL/CARB did not vary significantly over time (1.48% in 2016-2017, 1.89% in 2017-2018, and 1.90% in 2018-2019), but a statistically significant association with the LTCF typology (ULDM, UMDR) was observed. HAIs were caused by K. pneumoniae (n = 51/54.3%), E. coli (n = 41/43.6%), or both (n = 2/2.1%), producing ESBL (96%) or carbapenemases (4%). Prior colonization (n = 14/16%) corresponded to seven Kp-CARB and seven Ec/Kp-ESBL. The worrying prevalence of patients acquiring HAIs by Ec/Kp-ESBL/CARB, associated with the estimated rates of those already colonized at admission, highlights a relevant role for LTCFs as a reservoir of Ec/Kp-ESBL/CARB. Epidemiological surveillance should be extended to the national level, and colonization screening at LTCF admission implemented systematically.

Keywords: Enterobacterales; colonization; epidemiological surveillance; extended-spectrum β-lactam antibiotics; resistance.

Figure 1

Prevalence of healthcare-associated infections (HAIs) by E. coli and/or K. pneumoniae producing ESBL or carbapenemases (Ec/Kp-ESBL/CARB) in the analyzed time periods.

Figure 2

Prevalence of healthcare-associated infections (HAIs) by E. coli and/or K. pneumoniae producing ESBL or carbapenemases (Ec/Kp-ESBL/CARB) by LTCF typology, in the analyzed time periods. UC, units of convalescence (internments for up to 30 consecutive days); UMDR, units of medium-term internment and rehabilitation (internments between 30 and 90 consecutive days); ULDM, units of long-term internment and maintenance (internments of more than 90 days) [20].

Figure 3

Temporal evolution of the occurrence of healthcare-associated infections (HAIs) by E. coli and/or K. pneumoniae producing ESBL or carbapenemases (Ec/Kp-ESBL/CARB) in each LTCF analyzed: (a) UC institutions (UC-A only started operating in 2018); (b) UMDR institutions (for UMDR-E only 2018–2019 data were available); (c) ULDM institutions (for ULDM-F only 2018–2019 data were available). UC, unit of convalescence (internments for up to 30 consecutive days); UMDR, unit of medium-term internment and rehabilitation (internments between 30 and 90 consecutive days); ULDM, unit of long-term internment and maintenance (internments of more than 90 days) [20].

Figure 4

Distribution of etiological agents of the healthcare-associated infections (HAIs) analyzed in this study by LTCF typology. UC, units of convalescence (internments for up to 30 consecutive days); UMDR, units of medium-term internment and rehabilitation (internments between 30 and 90 consecutive days); ULDM, units of long-term internment and maintenance (internments of more than 90 days) [20].

Figure 5

Temporal evolution of E. coli as an agent of the healthcare-associated infections (HAIs) analyzed in this study in the different LTCF typologies. UC, units of convalescence (internments for up to 30 consecutive days); UMDR, units of medium-term internment and rehabilitation (internments between 30 and 90 consecutive days); ULDM, units of long-term internment and maintenance (internments of more than 90 days) [20].