The epidemiology of carbapenem-resistant Enterobacterales in a single center in Oman
Keywords:carbapenem-resistant Enterbacterales, carbapenemase, epidemiology, surveillance, Oman
Background: Carbapenem-resistant Enterobacterales (CRE) are a global public health threat associated with significant morbidity and mortality.
Objectives: The study aims to describe the epidemiology, microbiology and outcome of patients with CRE infection or colonization during an active surveillance program and to determine the risk factors for the acquisition of such organisms in a single center in Oman.
Method: A retrospective case–control study was conducted in a tertiary care hospital in 2015 and 2016. Cases included patients who had a positive screening or clinical sample for CRE and controls included patients who were screened during the same period and never had a positive screening or clinical sample for CRE. Risk factors analyzed were demographics, comorbidities, instrumentation, and antibiotic exposures. Data were analyzed using SPSS for Windows (version 11.5). Variables of interest were analyzed by univariate analysis, and those of significance were analyzed by logistic regression.
Results: Seven hundred and twenty-eight cases were detected from active surveillance screening, and clinical samples and 749 controls were included. Males comprised 417 (57.3%) cases and females 311 (42.7%). The majority of CRE cases were adult patients (88%, n = 644) compared to 12 % (n = 84) paediatric. The total number of CRE screenings was 8,431 samples in 2015 with a positivity rate of 4.2% and 10,231 samples in 2016 with a positivity rate of 3.6%. The annual incidence rate of CRE was 0.8 per 100 admissions in 2015 and 0.76 per 100 admissions in 2016. The annual incidence density was 1.90 and 1.89 per 1000 patient days for both years, respectively. Healthcare-associated acquisition was 99.5%, and only 0.5% was attributed to the community. The most common sites of infections were urine and wound comprising 29% each. Klebsiella pneumoniae (n = 578, 79%) was the predominant organism followed by Escherichia coli (n = 101, 14%). CRE acquisition was significantly associated with the presence of a urinary catheter (odds ratio [OR]: 7.3; confidence interval [CI]: 4.6–11.6; P < 0.0001 or central line (OR: 3.5; CI: 2.068–6.011; P < 0.001), intubation (OR: 0.5; CI: 0.264–0.947; P < 0.034), antibiotic exposure (OR: 4.5; CI: 3.101–6.586; P < 0.0001), and intensive care unit (ICU) admission (OR: 0.5; CI: 0.297–0.852; P = 0.011). In addition, history of a local and an abroad hospital admission significantly increased the risk of CRE acquisition (respectively, local OR: 10.97; CI: 7.878–15.301; P < 0.000, abroad OR: 12.4; CI: 6.597–23.617; P < 0.0001). Overall mortality was 23.1 and 52.3% among bacteremia cases.
Conclusion: The annual incidence of CRE acquisition is high with a high mortality rate. A multifaceted strategy to control the spread of CRE is fundamental, considering the specific epidemiology of CRE related to our institution and country.
Marimuthu K, Venkatachalam I, Khong WX, Koh TH, Cherng BPZ, Van La M, et al. Clinical and molecular epidemiology of carbapenem-resistant enterobacteriaceae among adult inpatients in Singapore. Clin Infect Dis. 2017; 64(suppl_2): S68–75. doi: 10.1093/cid/cix113
Poirel L, Al Maskari Z, Al Rashdi F, Bernabeu S, Nordmann P. NDM-1-producing Klebsiella pneumoniae isolated in the Sultanate of Oman. J Antimicrob Chemother. 2011; 66(2): 304–6. doi: 10.1093/jac/dkq428
Potron A, Nordmann P, Lafeuille E, Al Maskari Z, Al Rashdi F, Poirel L. Characterization of OXA-181, a carbapenem-hydrolyzing class D beta-lactamase from Klebsiella pneumoniae. Antimicrob Agents Chemother. 2011; 55(10): 4896–9. doi: 10.1128/AAC.00481-11
Dortet L, Poirel L, Al Yaqoubi F, Nordmann P. NDM-1, OXA-48 and OXA-181 carbapenemase-producing Enterobacteriaceae in Sultanate of Oman. Clin Microbiol Infect. 2012; 18(5): E144–8. doi: 10.1111/j.1469-0691.2012.03796.x
Sonnevend A, Ghazawi AA, Hashmey R, Jamal W, Rotimi VO, Shibl AM, et al. Characterisation of CRE in the Arabian Peninsula. PLoS One. 2015; 10(6): e0131372. doi: 10.1371/journal.pone.0131372
Balkhair A, Al-Farsi YM, Al-Muharrmi Z, Al-Rashdi R, Al-Jabri M, Neilson F, et al, Epidemiology of multi-drug resistant organisms in a teaching hospital in oman: a one-year hospital-based study. ScientificWorldJournal. 2014; 2014: 157102: 6 pages. doi: 10.1155/2014/157102
STROBE. Strengthening the reporting of observational studies in epidemiology. Available from: https://www.strobe-statement.org/checklists/ [cited March 2019].
Performance Standards for Antimicrobial Susceptibility Testing. 26th Edition. CLSI M100-S26, Clinical Laboratory Standard Institute, CLSI; 2016, Available from: https://clsi.org›microbiology›documents›m100 [cited January 2018]
Kelly AM, Mathema B, Larson EL. Carbapenem-resistant Enterobacteriaceae in the community: a scoping review. Int J Antimicrob Agents. 2017; 50(2): 127–34. doi: 10.1016/j.ijantimicag.2017.03.012
Tang HJ, Hsieh CF, Chang PC, Chen JJ, Lin YH, Lai CC, et al. Clinical significance of community- and healthcare-acquired carbapenem-resistant Enterobacteriaceae isolates. PLoS One. 2016; 11(3): e0151897. doi: 10.1371/journal.pone.0151897
Adesanya OA, Igwe HA. Carbapenem-resistant Enterobacteriaceae (CRE) and gram-negative bacterial infections in south-west Nigeria: a retrospective epidemiological surveillance study. AIMS Public Health. 2020; 7(4): 804–15. doi: 10.3934/publichealth.2020062
Teo J, Cai Y, Tang S, Lee W, Tan TY, Tan TT, et al. Risk factors, molecular epidemiology and outcomes of ertapenem-resistant, carbapenem-susceptible enterobacteriaceae: a case-case-control study. PLoS One. 2012; 7(3): e34254. doi: 10.1371/journal.pone.0034254
van Loon K, Voor In ‘t Holt AF, Vos MC. A systematic review and meta-analyses of the clinical epidemiology of Carbapenem-resistant Enterobacteriaceae. Antimicrob Agents Chemother. 2017; 62(1): e01730-17. doi: 10.1128/AAC.01730-17
Garbati MA, Sakkijha H, Abushaheen A. Infections due to Carbapenem resistant enterobacteriaceae among Saudi Arabian hospitalized patients: a matched case-control study. Biomed Res Int. 2016; 2016: 3961684. doi: 10.1155/2016/3961684
Zarakolu P, Eser OK, Aladag E, Al-Zahrani IA, Day KM, Atmaca O, et al. Epidemiology of carbapenem-resistant Klebsiella pneumoniae colonization: a surveillance study at a Turkish university hospital from 2009 to 2013. Diagn Microbiol Infect Dis. 2016; 85: 466–70. doi: 10.1016/j.diagmicrobio.2016.05.012
Falagas ME, Tansarli GS, Karageorgopoulos DE, Vardakas KZ. Deaths attributable to carbapenem-resistant Enterobacteriaceae infections. Emerg Infect Dis. 2014; 20(7): 1170–5. doi: 10.3201/eid2007.121004
Tamma PD, Goodman KE, Harris AD, Tekle T, Roberts A, Taiwo A, et al. Comparing the outcomes of patients with carbapenemase-producing and non-carbapenemase-producing carbapenem-resistant Enterobacteriaceae Bacteremia. Clin Infect Dis. 2017; 64(3): 257–64. doi: 10.1093/cid/ciw741
Li X, Ye H. Clinical and mortality risk factors in bloodstream infections with Carbapenem-Resistant enterobacteriaceae. Can J Infect Dis Med Microbiol. 2017; 2017: 6212910. doi: 10.1155/2017/6212910
How to Cite
Authors retain copyright of their work, with first publication rights granted to IJIC. Read the full Copyright- and Licensing Statement.