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Year : 2015  |  Volume : 33  |  Issue : 4  |  Page : 612--613

Asymptomatic colonization with carbapenem resistant enterobacteriaceae (CRE) in ICU patients and its associated risk factors: Study from North India

P Datta, V Gupta, N Singla, J Chander 
 Department of Microbiology, Government Medical College Hospital, Chandigarh, India

Correspondence Address:
P Datta
Department of Microbiology, Government Medical College Hospital, Chandigarh
India

How to cite this article:
Datta P, Gupta V, Singla N, Chander J. Asymptomatic colonization with carbapenem resistant enterobacteriaceae (CRE) in ICU patients and its associated risk factors: Study from North India.Indian J Med Microbiol 2015;33:612-613

How to cite this URL:
Datta P, Gupta V, Singla N, Chander J. Asymptomatic colonization with carbapenem resistant enterobacteriaceae (CRE) in ICU patients and its associated risk factors: Study from North India. Indian J Med Microbiol [serial online] 2015 [cited 2020 Jul 7 ];33:612-613
Available from: http://www.ijmm.org/text.asp?2015/33/4/612/167316

Full Text

Dear Editor,

Colonisation with carbapenem-resistant enterobacteriaceae (CRE) is defined as the presence, growth and multiplication of this organism, in a patient, without any observable clinical signs and symptoms of infections. The majority of people who acquire CRE are colonised rather than infected.[1] The primary site of colonisation is the lower gastrointestinal tract. Patients colonised with CRE are more likely to contaminate environmental surfaces, equipments and hands of HCWs.[1] The aim of this study was to find the prevalence of CRE colonisation in intensive care unit (ICU) patients and risk factors associated with it. This prospective study was conducted in our 750-bedded hospital having two multidisciplinary ICUs consisting of five and ten beds each; from 1 July 2012 to 31 December 2012.

All the patients were grouped into two groups: CRE group (those who had CRE colonisation in their rectal swab) and non-CRE group (those who did not have CRE colonisation in their rectal swab) to determine the risk factors associated with colonisation with CRE. Rectal swabs were collected from all patients after 48 hours of ICU admission. These patients were compared regarding presence of co-morbidity (diabetes mellitus, chronic heart disease, pulmonary disease, renal disease, hepatic disease, central nervous system disease and malignancy), prior use of antibiotics (carbapenem, cephalosporins, fluoroquinolones and metronidazole), presence of wounds (surgical or trauma), prior surgery and intra-hospital transfer. Prior use of antimicrobial was considered significant only if (i) That exposure had occurred only during the hospitalization in which colonisation had developed and (ii) the antibiotic had been administered for at least 3 consecutive days prior to the development of the colonisation. The laboratory detection of CRE from rectal swab was done as per technique described by Centre for Disease Control and Prevention (CDC).[2] All these isolates were confirmed to be CRE by testing for susceptibility to ertapenem (10 µg)/meropenem (10 µg) (BD, Diagnostics) by disc diffusion method according to Clinical Laboratory Standard Institute (CLSI) criteria.[3] Comparison of various risk factors in patients colonised with CRE with those not having CRE colonisation was done. Odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were calculated. In 6-months period, 75 patients were enrolled in this prospective case-control study. Rectal swab screening of these patients showed that 9 of these 75 patients admitted in ICU had rectal carriage of CRE and 66 patients did not have CRE in their rectal swabs. Six were Escherichia coli strains and three were Klebsiella species. Therefore, the percentage of CRE carriage was 12%. Patients with CRE colonisation were more likely to be having associated co-morbidity like hepatic disease (OR = 1.16) and renal disease (OR = 1.05). Additionally, CRE colonisation was more likely in those patients who had prior exposure to carbapenem (OR = 3.29), cephalosporin (OR = 1.31), fluoroquinolones (OR = 3.19) and metronidazole (OR = 1.7). Moreover, presence of wounds (OR = 1.69), prior surgery (OR = 1.41) and intra-hospital transfer (OR = 1.07) were more likely in patients with CRE colonisation as compared to patients not having CRE colonisation.

No study from India has detected CRE colonisation but the prevalence of CRE infections varies from 13–51%.[4] The combination of multiple co-morbidities, presence of wound and surgery and intra-hospital transfer, makes the patients ideal candidates for the acquisition and transmission of genes for drug resistance. Gupta N et al. reported that exposure to antimicrobial like carbapenem, cephalosporins, fluoroquinolones, vancomycin; longer hospital stay; poor functional status are all associated with infections due to CRE.[5]

The clinical implication of our findings is that antimicrobial agent especially carbapenem, cephalosporins, fluoroquinolones and metronidazole should be used with caution for CRE carriers. CDC recommends the following measures for the control of CRE-hand hygiene; contact precautions including patient and staff cohorting, minimizing device use; chlorhexidine bathing; routine use of clinical laboratory screening tests for accurate detection of CRE; screening surveys on admission for patients at high risk of CRE colonisation and antimicrobial stewardship.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wiener-Well Y, Rudensky B, Yinnon AM, Kopuit P, Schlesinger Y, Broide E, et al. Carriage rate of carbapenem-resistant Klebsiella pneumoniae in hospitalized patients during a national outbreak. J Hosp Infect 2010;74:344-9.
2Available from: http://www.cdc.gov/ncidod/dhqp/pdf/ar/klebsiellaor E. coli.pdf [Last accessed on 2011 Oct 24].
3Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty First Informational Supplement M100-S21. Wayne: CLSI; 2011.
4Wattal C, Goel N, Oberoi JK, Raveendran R, Datta S, Prasad KJ. Surveillance of multidrug resistant organisms in a tertiary care hospital in Delhi, India. J Assoc Physicians India 2010;58 Suppl: 32-6.
5Gupta N, Limbago BM, Patel JB, Kallen AJ. Carbapenem-resistant enterobacteriaceae: Epidemiology and prevention. Clin Infect Dis 2011;53:60-7.