Carbapenemases producer Gram negative bacilli infections : surveillance results 2014–2015

From April 1, 2014, to March 31, 2015, 67 healthcare facilities (participation rate: 75.2%) took part in the surveillance of carbapenemase-producing Gram negative bacilli (CPGNB) infections, for a total of 3,225,934 patient-days (Table 1).

In total, 9 CPGNB infections were reported among patients who acquired their strain during a current or previous hospital stay in the reporting facility (categories 1a + 1b). The incidence rate of healthcare-associated CPGNB infection (cat. 1a + 1b) was 0.028 / 10,000 patient days. The acquisition rate of healthcare-associated CPGNB colonization (cat. 1a + 1b) was 0.16 / 10,000 patient days. Data was extracted on May 20th, 2015 and updated on June 1, 2015 for complications. 

Updated : March 24, 2016

Table 1 – Participation of Healthcare Facilities in the Surveillance of CPGNB Infections, Québec, 2014-2015

 2014-2015
Participating facilities (N)67
Admissions (N)432,363
Inpatient-days (N)3,225,934
Cases of healthcare-associated CPGNB infection (cat. 1a + 1b) (N)9
Cases of healthcare-associated CPGNB colonization (cat. 1a + 1b) (N)52
Infected patients (N)8

In 2014–2015, the incidence rate of healthcare-associated CPGNB infection (cat. 1a + 1b) was 0.028/10,000 patient-days (table 2).  

Teaching healthcare facilities have a higher incidence rate of healthcare-associated CPGNB infection than non teaching facilities (table 2).

Table 2 – Incidence Rate and Percentile Distribution of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) by Type of Healthcare Facility, Québec, 2014–2015 (Incidence Rate per 10,000 Patient-Days [95% CI])

Type of FacilityMin.25 %50 %75 %90 %Max.Incidence Rate
Non-teaching (N = 45)0.0570.0570.0570.0570.0570.0570.007 [0-0.027]
Teaching (N = 22)0.0690.0910.1220.2360.5580.5580.046 [0.020-0.083]¥
Total (N = 67)0.0570.0690.1190.2360.5580.5580.028 [0.013-0.049]

[I.C. 95 %] : 95% confidence interval.
¥ Significant statistical difference (p < 0.05) between non-teaching and teaching healthcare facilities.

In total, 67 colonizations (including 14 infections) of CPGNB were reported: 54 (80.6%) were identified in patients who acquired their CPGNB during a current hospital stay (9 infections and 51 colonizations), during a previous hospital stay (1 colonization) or in ambulatory care of the reporting facility (1 infection and 2 colonizations) (cat. 1a, 1b and 1c.). A total of 13 colonizations were associated to another facility (2 infections and 6 colonizations), to the community (2 colonizations) or remained unknown (2 infections and 5 colonizations) (cat. 2, 3 and 4) (table 3).

Table 3 – Cases of CPGNB Infections and Colonizations by Presumed Source of Acquisition, Québec, 2014–2015 (N, %)

CategorySource of AcquisitionInfectionColonization*
1aHealthcare-associated with a current hospital stay in the reporting facility9 (64.3 %)51 (76.1 %)
1bHealthcare-associated with a previous hospital stay in the reporting facility0 (0 %)1 (1.5 %)
1cHealthcare-associated with ambulatory care in the reporting facility1 (7.1 %)2 (3 %)
1dHealthcare-associated with long-term unit in the reporting facility0 (0 %)0 (0 %)
1eHealthcare-associated with psychiatry unit in the reporting facility0 (0 %)0 (0 %)
2Healthcare-associated with another facility2 (14.3 %)6 (9 %)
3Community0 (0 %)2 (3 %)
4Unknown2 (14.3 %)5 (7.5 %)
 Total1467

* Colonizations included infections.

In 2014-2015, among 14 infections, no primary bloodstream infection (BSI) was observed. However, two secondary bloodstream infections have been reported (Table 4).

Table 4 – Number of Cases of CPGNB Infections from All Sources by Type of Infection and Number of Complications (Secondary BSIs), Québec, 2014–2015 (N = 14)

Type of InfectionInfections
(N)
Secondary Bloodstream
Infections (N)
Primary BSI  
   CRBSI-MBI0-
   CRBSI0-
   Non- CRBSI-MBI0-
   Non-CRBSI0-
   HD0-
   
Others  
   Surgical site50
   Urinary tract30
   Abdominal31
   Pulmonary21
   Skin and soft tissus10
   Bones and joints00
   Others00
Total142

BSI : bloodstream infection
CRBSI : catheter-related bloodstream infection
MBI : mucosal barrier injury
Non-CRBSI : non-catheter-related primary bloodstream infection
HD: hemodialysis

A total of 5 deaths within 30 days were observed, yielding an all cause case-fatality of 35.7% (Table 5).

Table 5 – Number of Deaths and 30-days all cause case-fatality in Patients Infected by a CPGNB, Québec, 2014-2015

 2014-2015
CPGNB infections (all sources)14
Number of deaths5
All cause case-fatality35.7 %

Table 6 – Risk Factors Associated With CPGNB colonization, Québec, 2014-2015

Risk FactorsNew carrierKnown carrier
N = 3
Undefined carrier
N = 13
 No contact with
a known carrier
N = 42
Contact with
a known carrier
N = 9
Contact with known carrier-9-7
Healthcare abroad3--2
Travel abroad in the last 12 months8---
     
Other risks    
Carba-3GC*-Fluo31-4
No Carba-3GC-Fluo71--
Diabetes4--2
Acute renal failure2-1-
Chronic renal failure--12
Non hematologic active neoplasia1321-
Solid organ transplant3---

* 3GC: 3rd generation cephalosporin.
Carba-3GC-Fluo: Taking a carbapenem / 3rd generation cephalosporin / fluoroquinolone in the last two weeks prior to diagnosis.
Carba-3GC-Fluo: Taking a carbapenem / 3rd generation cephalosporin / fluoroquinolone in the last two weeks prior to diagnosis.

In 2014-2015, the acquisition rate of healthcare-associated CPGNB colonization (cat. 1a + 1b) was 0.16 / 10,000 patient days (table 7).

Table 7 – Change in the Number of Cases and Acquisition Rate of Healthcare-associated CPGNB  Colonization (Cat. 1a + 1b) by Type of Healthcare Facility, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000  patient-days)

 2014-2015
Type of FacilityNumber of ColonizationAcquisition Rate of HA-CPGNB  Colonization
Non-teaching (N = 45)330.22 [0.15-0.31]
Teaching (N = 22)190.11 [0.07-0.16]
Total (N = 67)520.16 [0.12-0.21]

Table 8 shows the number of non-teaching facilities that identified the type of screening used at admission (29 out of 45) and during hospitalization (26 out of 45). About two-thirds of teaching facilities identified the type of screening used at admission (16 out of 22) and during hospitalization (16 out of 22).

Table 8 – Number of Healthcare Facilities that Identified the type of Screening Procedure Used at Admission and During Hospitalization by Type of Facility, Québec, 2014-2015

 Number of Facilities That Identified the Type of Screening Procedure Used*
Type of FacilityAt admissionDuring HospitalizationTotal
Non-teaching (N = 45)292633
Teaching (N = 22)161617
Total (N = 67)454250

* The "at admission" and "during hospitalization" categories are not mutually exclusives.

Tables 9 and 10 feature the total number of screening tests performed at admission and during hospitalization, as well as the mean number of CPGNB screening tests per admission.

Table 9 – Total Number of Screening Tests Performed at Admission and During Hospitalization by Type of Healthcare Facility, Québec, 2014-2015

 Total Number of Screening Tests
Type of FacilityAt admissionDuring HospitalizationUnspecifiedTotal
Non-teaching 2,6198,10279511,516
Teaching 10,68617,4172928,132
Total13,30525,51982439,648

Table 10 – Mean Number of CPGNB Screening Tests by Type of Healthcare Facility, Québec, 2014-2015 (Mean CPGNB Screening Tests per Admission)

 Mean Number of CPGNB Screening Tests
Type of FacilityAt admissionDuring HospitalizationTotal
(N)
Non-teaching 0.0130.0400.057
Teaching 0.0460.0750.121
Total0.0310.0590.092

Figure 1 features the distribution of microorganisms isolated from all cases. A total of 35 colonizations were due to Citrobacter freundii (52 %), 11 colonizations were due to Klebsiella pneumonia (16 %) and 7 were due to Enterobacter cloacae (10 %). Most deaths occurred in patients with KPC-producing Klebsiella pneumonia (n = 5; 62.5%). All 8 deaths occurred in patients with KPC-producing microorganisms.

Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Isolated Microorganisms - All Cases
Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Isolated Microorganisms – Deaths at 30 Days (N = 8)
Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Table 11 presents the resistance profile as reported by the healthcare facilities towards carbapenems of all reported microorganisms (colonization and infection). All the E. coli, K. oxytoca, S. marcescens and Serratia spp. were ertapenem resistant (100%). All the A. baumanii, E. cloacae, E. coli, K. oxytoca, Klebsiella spp, and Serratia spp. were meropenem resistant (100%).

Table 11 – Resistance Profile Towards Carbapenem of CPGNB Microorganisms isolated, Québec, 2014-2015

MicroorganismNAntibioticsResistants
N%
Acinetobacter baumannii3Doripenem266.7
  Imipenem3100.0
  Meropenem3100.0
Citrobacter freundii35Ertapenem3291.4
  Imipenem1234.3
  Meropenem2880.0
Enterobacter cloacae7Ertapenem457.1
  Imipenem685.7
  Meropenem7100.0
Escherichia coli5Ertapenem5100.0
  Imipenem480.0
  Meropenem5100.0
Klebsiella oxytoca4Ertapenem4100.0
  Imipenem250.0
  Meropenem4100.0
Klebsiella pneumoniae12Ertapenem1191.7
  Imipenem975.0
  Meropenem1191.7
Klebsiella spp.1Ertapenem1100.0
  Meropenem1100.0
Serratia marcescens1Ertapenem1100.0
  Imipenem1100.0
Serratia spp.1Ertapenem1100.0
  Imipenem1100.0
  Meropenem1100.0

Table 12 shows the carbapenemase gene detected for every microorganisms reported during the surveillance period (colonization and infection). Among the 67 cases, one infection was associated with two different CPGNB (1 NDM-producing Escherichia coli and 1 OXA-48 producing Klebsiella pneumonia). Also, one patient was colonizationed by two different CPGNB (1 KPC-producing Escherichia coli and 1 KPC-producing Klebsiella oxytoca). Finally, one Klebsiella pneumonia strain produced both OXA-48 and NDM.

Table 12 – Distribution of Carbapenemase-encoding Genes from Reported Microorganisms, Québec, 2014-2015

MicroorganismNo IsolatedGeneN% gene among
microorganism
Acinetobacter baumannii3OXA-233100.0
Citrobacter freundii35KPC35100.0
Enterobacter cloacae7KPC685.7
  NMC114.3
Escherichia coli5KPC120.0
  NDM360.0
  OXA-48120.0
Klebsiella oxytoca4KPC4100.0
Klebsiella pneumoniae12KPC969.2
  OXA-4817.7
  OXA-48/NDM17.7
  VIM17.7
Other Klebsiella spp.1OXA-481100.0
Serratia marcescens1SME1100.0
Serratia spp.1SME1100.0
Total69   

KPC: Klebsiella pneumonia carbapenemase (Class A).
NDM: New-Dehli metallo--lactamase (Class B).
NMC: Not metalloenzyme carbapenemase.
OXA-23: Oxacillinase-23 (Class D).
OXA-48: Oxacillinase-48 (Class D).
SME: Serratia marcescens enzyme.
VIM: Verona integron-encoded metallo--lactamase (Class B).

The incidence rate of HA-CPGNB infection and the percentile rankings by type of facility are shown in figure 2 and 3. Figure 4 and 5 present the rate of acquisition of healthcare-associated colonization by type of facility.

Figure 2 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB infection (Cat. 1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

Figure 2 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB infection (Cat. 1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

NB: Facilities 9, 11, 16, 23, 26, 32, 34, 35, 36, 37, 40, 42, 45, 46, 47, 49, 52, 53, 56, 58, 61, 63, 64, 65, 67, 71, 74, 75, 77, 81, 82, 83, 84, 85, 88, 89, 91, 97, 100, 103, 107, 109, 113 and 130 did not report any cases of infection in 2014-2015.

Figure 3 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

Figure 3 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

 NB: Facilities 2, 6, 8, 12, 13, 15, 18, 20, 21, 24, 27, 28, 30, 31, 116 and 118 did not report any cases of infection in 2014-2015.

Figure 4 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

Figure 4 – Taux d’acquisition des colonisations nosocomiales à BGNPC (cat. 1a + 1b) dans les installations non universitaires, Québec, 2014-2015 (taux d’acquisition des colonisations nosocomiales à BGNPC par 10 000 jours-présence)

NB: Facilities 9, 11, 16, 23, 26, 32, 34, 35, 36, 37, 40, 42, 45, 46, 47, 49, 52, 53, 56, 61, 63, 64, 65, 67, 71, 74, 75, 77, 81, 82, 83, 84, 85, 88, 89, 91, 97, 100, 103, 107, 109, 113 and 130 did not report any cases of colonization in 2014-2015.

Figure 5 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

Figure 5 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

NB: Facilities 2, 6, 8, 12, 13, 15, 18, 20, 21, 24, 27, 28, 30, 31, 116 et 118 did not report any cases of colonization in 2014-2015.

At the local level, in 2014-2015, the incidence rate of HA-CPGNB infections ranged from 0 to 0.56 / 10,000 patient-days, whereas the acquisition rate of HA-CPGNB colonization ranged from 0 to 4.81 / 10,000 patient-days. A total of 60 facilities (89.6%) did not report any HA-CPGNB infection or colonization in 2014-2015. A detailed summary of the surveillance data for HA-CPGNB infection by healthcare facility can be found in table 13.

Table 13 – Incidence Rate of Healthcare-Associated CPGNB Infection (cat. 1a + 1b), Acquisition Rate of Healthcare-Associated CPGNB Colonization and Mean CPGNB Screening Tests by Admission and by Facility, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days [95% CI]; Acquisition Rate of Colonization per 10,000 Patient-Days)

Health
Region
FacilityIncidence Rate of HA-CPGNB Infection (cat. 1a + 1b)
[95% CI]
Acquisition Rate of HA-CPGNB Colonization
(cat. 1a + 1b)
Mean CPGNB Screening Tests per Admission*
NumberName
0116HÔPITAL RÉGIONAL DE RIMOUSKI000.149
32CENTRE HOSPITALIER RÉGIONAL DU GRAND-PORTAGE000.016
61HÔPITAL NOTRE-DAME-DE-FATIMA000.011
71HÔPITAL DE MATANE000.002
77HÔPITAL D'AMQUI00-
84HÔPITAL DE NOTRE-DAME-DU-LAC00-
 BAS-SAINT-LAURENT000.070
0220HÔPITAL DE CHICOUTIMI000
67HÔPITAL ET CENTRE DE RÉADAPTATION DE JONQUIÈRE000.137
74HÔPITAL DE DOLBEAU-MISTASSINI000.002
88HÔPITAL, CLSC ET CENTRE D'HÉBERGEMENT DE ROBERVAL00-
100HÔPITAL DE LA BAIE00-
 SAGUENAY–LAC-SAINT-JEAN000.021
032HÔPITAL DE L'ENFANT-JÉSUS000.066
7PAVILLON L'HÔTEL-DIEU DE QUÉBEC0.12 [0-0.47]0.120.015
24HÔPITAL DU SAINT-SACREMENT000.021
27PAVILLON CENTRE HOSPITALIER DE L'UNIVERSITÉ LAVAL000.014
28PAVILLON SAINT-FRANÇOIS D'ASSISE000.006
33INSTITUT UNIVERSITAIRE DE CARDIOLOGIE ET DE PNEUMOLOGIE DE QUÉBEC0.13 [0-0.49]0.500.184
 CAPITALE-NATIONALE0.04 [0-0.10]0.090.051
0423HÔTEL-DIEU D'ARTHABASKA000.007
31PAVILLON SAINT-JOSEPH000.004
85CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DU HAUT-SAINT-MAURICE00-
 MAURICIE ET CENTRE-DU-QUÉBEC000.005
0515HÔPITAL FLEURIMONT00-
30HOTEL-DIEU DE SHERBROOKE00-
49CENTRE DE SANTÉ ET DE SERVICES SOCIAUX MEMPHRÉMAGOG00-
75CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DU GRANIT00-
 ESTRIE000
063HÔPITAL ROYAL VICTORIA0.09 [0-0.36]0.090.015
4HÔPITAL NOTRE-DAME DU CHUM0.56 [0.05-1.60]0.84-
5HÔPITAL GÉNÉRAL JUIF0.07 [0-0.27]0.561.280
6L'HÔPITAL DE MONTRÉAL POUR ENFANTS000.002
8PAVILLON MAISONNEUVE/PAVILLON MARCEL-LAMOUREUX000.066
12CENTRE HOSPITALIER UNIVERSITAIRE SAINTE-JUSTINE00-
13INSTITUT DE CARDIOLOGIE DE MONTRÉAL000.090
21HÔPITAL SAINT-LUC DU CHUM00-
26HÔPITAL DE VERDUN000.011
29HÔPITAL GÉNÉRAL DE MONTRÉAL0.24 [0.02-0.68]0.240.061
34HÔPITAL SANTA CABRINI00-
36HÔPITAL GÉNÉRAL DU LAKESHORE000.964
83HÔPITAL DE LASALLE000.014
116INSTITUT THORACIQUE DE MONTRÉAL000.024
118HÔPITAL NEUROLOGIQUE DE MONTRÉAL000.034
 MONTRÉAL0.07 [0.03-0.14]0.160.257
0740HÔPITAL DE HULL000.001
 OUTAOUAIS000.001
0847HÔPITAL DE ROUYN-NORANDA000.028
52HÔPITAL D'AMOS000.001
65HÔPITAL ET CLSC DE VAL-D'OR00-
82PAVILLON SAINTE-FAMILLE000.102
 ABITIBI-TÉMISCAMINGUE000.019
0964HÔPITAL LE ROYER000.009
 CÔTE-NORD000.009
1153HÔPITAL DE CHANDLER00-
91HÔPITAL HÔTEL-DIEU DE GASPÉ00-
97HÔPITAL DE MARIA000.024
107HÔPITAL DE L'ARCHIPEL000.031
109HÔPITAL DE SAINTE-ANNE-DES-MONTS000.013
 GASPÉSIE–ÎLES-DE-LA-MADELEINE000.012
1218HÔTEL-DIEU DE LÉVIS000.009
63HÔPITAL DE SAINT-GEORGES000.003
89HÔPITAL DE MONTMAGNY000.088
113HÔPITAL DE THETFORD MINES000.013
 CHAUDIÈRE-APPALACHES000.017
1319HÔPITAL CITÉ DE LA SANTÉ0.06 [0-0.22]0.340.115
 LAVAL0.06 [0-0.22]0.340.115
1411HÔPITAL PIERRE-LE GARDEUR000.020
 LANAUDIÈRE000.020
1545HÔPITAL DE SAINT-EUSTACHE000.007
56CENTRE DE SANTÉ ET DE SERVICES SOCIAUX D'ARGENTEUIL000.043
81HÔPITAL DE MONT-LAURIER000.004
103HÔPITAL LAURENTIEN000.002
 LAURENTIDES000.008
169HÔPITAL DU HAUT-RICHELIEU000
35HÔPITAL HONORÉ-MERCIER000.027
37HÔTEL-DIEU DE SOREL000.001
42CENTRE HOSPITALIER ANNA-LABERGE000.060
46HÔPITAL DE GRANBY00-
58HÔPITAL DU SUROÎT04.810.373
130HÔPITAL BARRIE MEMORIAL000.487
 MONTÉRÉGIE00.700.75
  Total0.03 [0.01-0.05]0.160.092

* Number of screening test divided by number of admisions.

Comité de surveillance provinciale des infections nosocomiales (SPIN)

Editorial Committee 

Christophe Garenc, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Muleka Ngenda-Muadi, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Mélissa Trudeau, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Christian Lavallée, Hôpital Maisonneuve-Rosemont