Carbapenemase-Producing Gram Negative Bacilli (CPGNB) Infections - surveillance 2015-2016

In 2015–2016, the incidence rate of healthcare-associated CPGNB infection (cat. 1a and 1b) was 0.011 per 10,000 patient days in all participating healthcare facilities (Table 2).

All reported infections occurred in teaching healthcare facilities (Table 2).

Table 2 – Incidence Rate and Percentile Distribution of Healthcare-Associated CPGNB Infection (Cat. 1a and 1b) by Type of Healthcare Facility, Québec, 2015–2016 (Incidence Rate per 10,000 Patient Days [95% CI])

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

Among the 63 healthcare facilities participating in the two years of surveillance, the incidence rate of healthcare-associated CPGNB infections in 2015-2016 was 0.012 per 10,000 patient days and it was half the incidence rate observed in 2014-2015 (Table 3)

Table 3 – Change in Incidence Rate of Healthcare-Associated CPGNB infection (Cat1. 1a and 1b) by Type of Healthcare Facility, Québec, 2014-2015 to 2015–2016 (Incidence Rate per 10,000 Patient Days [95% CI])

* Number of facilities participating in each of the two years of surveillance.

In total, 98 colonizations (including 6 infections) of CPGNB were reported: 81 (82.6%) were identified in patients who acquired their CPGNB colonization during a current hospital stay (3 infections and 68 colonizations), during a previous hospital stay (1 infection and 2 colonizations) or in ambulatory care of the reporting facility (7 colonizations) (cat. 1a, 1b and 1c). One infection have been observed in a patient from the psychiatry unit. A total of 7 colonizations were associated to another facility (1 infection and 6 colonizations), to the community (7 colonizations) or remained unknown (2 colonizations) (cat. 2, 3 and 4) (Table 4).

Table 4 – Cases of CPGNB Infections and Colonizations by Presumed Origin of Acquisition, Québec, 2015–2016
(N, %)

Note: Colonizations included infections.

In 2015-2016, among 6 infections, no primary bloodstream infection (BSI) was observed (Table 5).

Table 5 – Number of Cases of CPGNB Infections from All Origins by Type of Infection and Number of all Origin CPGNB Secondary BSIs , Québec, 2015–2016 (N = 6)

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

No deaths within 30 days were observed following onset of infection (Table 6).

Table 6– Number of Deaths and 30-days all Cause Case-fatality in Patients Infected by a CPGNB, Québec, 2015-2016

Table 7 – Risk Factors Associated With CPGNB Colonization, Québec, 2014-2015

* 3GC: 3^rd generation cephalosporin.
Carba-3GC-Fluo: Taking a carbapenem/3^rd generation cephalosporin/fluoroquinolone in the last two weeks prior to diagnosis.
No Carba-3GC-Fluo: not taking a carbapenem/3^rd generation cephalosporin/fluoroquinolone in the last two weeks prior to diagnosis.

In 2015-2016, the acquisition rate of healthcare-associated CPGNB colonization (cat. 1a and 1b) was 0.215 per 10,000 patient days among healthcare facilities participating in the two years of surveillance (Table 8) and was 0.197 per 10,000 patient days among all facilities in 2015-2016 (Table 14).

Table 8 – Change in the Number of Cases and Acquisition Rate of Healthcare-associated CPGNB Colonization (Cat. 1a and 1b) by Type of Healthcare Facility, Québec, 2014-2015 to 2015-2016 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 patient days)

* Number of facilities participating in each of the two years of surveillance.

Table 9 shows the number of non-teaching facilities that indicated the type of screening used at admission (non-teaching: 34 out of 51; teaching: 14 out of 22) and during hospitalization (non-teaching: 27 out of 51; teaching: 16 out of 22).

Table 9 – Number of Healthcare Facilities that Indicated the Type of Screening Procedure Used at Admission and During Hospitalization by Type of Facility, Québec, 2015-2016

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

Tables 10 and 11 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 10 – Total Number of Screening Tests Performed at Admission and During Hospitalization by Type of Healthcare Facility, Québec, 2015-2016

Table 11 – Mean Number of CPGNB Screening Tests by Type of Healthcare Facility, Québec, 2014-2015 (Mean CPGNB Screening Tests per Admission), Québec, 2015-2016

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

Figure 1 features the distribution of microorganisms isolated from all cases. A total of 111 microorganisms have been isolated from 98 colonizations. Identified microorganisms were Citrobacter freundii (44.1%), Klebsiella pneumonia (17.1%), Enterobacter cloacae (16.2%) or Escherichia coli (10.8%). For seven colonization cases, two microorganisms have been isolated, whereas for one colonization, a total of four distinct microorganisms have been isolated.

Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67), Québec, 2015-2016

Isolated Microorganisms - All Cases (n = 111)

Table 12 presents the proportion of tested strains for sensitivity or resistance to carbapeneme (doripenem, ertapenem, imipenem and meropenem) as well as percentage of resistance among isolated strains.

All the Enterobacter cloacae, Citrobacter freundii, Klebsiella oxytoca, Klebsiella pneumoniae and Serratia marcescens were ertapenem resistant.

Table 12 – Resistance Profile Towards Carbapenem of CPGNB Microorganisms Isolated, Québec, 2015-2016

Note: Only microorganisms that have been tested for an antibiotic are represented.

Table 13 shows the carbapenemase gene detected for every isolated microorganisms. The majority of carbapenemase gene associated to different microorganism is KPC. One strain of Enterobacter cloacae, six strains of Escherichia coli and two strain of Klebsiella pneumoniae produced NDM. One Klebsiella pneumonia strain produced both OXA-48 and NDM.

Table 13 – Distribution of Carbapenemase-encoding Genes from Reported Microorganisms, Québec, 2015-2016

KPC : Klebsiella pneumoniae carbapenemase (Class A).
NDM : New-dehli metallo-b-lactamase (Class B).
NMC : Not metalloenzyme carbapenemase.
OXA-23 : Oxacillinase-23 (class D).
OXA-48 : Oxacillinase-48 (Class D).
SME : Serratia marcescens enzyme.

The incidence rate of healthcare-associated 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 CPGNB colonization by type of facility.

Figure 2 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB infection (Cat. 1a and 1b) for Non-Teaching Healthcare Facilities, Québec, 2015-2016 (Incidence Rate per 10,000 Patient Days)

NB: Non-teaching facilities reported no cases of infection in 2015-2016.

Figure 3 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB Infection (Cat. 1a and 1b) for Teaching Healthcare Facilities, Québec, 2015-2016 (Incidence Rate per 10,000 Patient Days)

NB: Facilities 2, 3, 5, 8, 12, 13, 15, 18, 20, 21, 24, 27, 28, 29, 30, 31, 33, 76 and 118 did not report any cases of infection in 2015-2016.

Figure 4 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a and 1b) for Non-Teaching Healthcare Facilities, Québec, 2015-2016 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient Days)

NB: Facilities 9, 11, 16, 23, 26, 32, 34, 35, 37, 39, 40, 42, 44, 45, 46, 47, 49, 51, 52, 53, 56, 59, 61, 65, 67, 70, 71, 74, 75, 77, 81, 82, 84, 85, 86, 88, 89, 91, 97, 99, 100, 101, 103, 107, 109, 112, 113 and 130 did not report any cases of colonization in 2015-2016.

Figure 5 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a and 1b) for Teaching Healthcare Facilities, Québec, 2015-2016 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient Days)

NB: Facilities 3, 8, 12, 13, 15, 18, 20, 28, 30, 31, 76 and 118 did not report any cases of colonization in 2015-2016.

At the local level, in 2015-2016, the incidence rate of healthcare-associated CPGNB infections ranged from 0 to 0.233 per 10,000 patient days, whereas the acquisition rate of healthcare-associated CPGNB colonization ranged from 0 to 6,603 per 10,000 patient days. A total of 60 facilities (82%) did not report any healthcare-associated CPGNB infection or colonization in 2015-2016. A detailed summary of the surveillance data for HA-CPGNB infection by healthcare facility can be found in table 14.

Table 14 – Incidence Rate of Healthcare-Associated CPGNB Infection (cat. 1a and 1b), Acquisition Rate of Healthcare-Associated CPGNB Colonization and Mean CPGNB Screening Tests by Admission and by Facility, Québec, 2015-2016 (Incidence Rate per 10,000 Patient Days [95% CI]; Acquisition Rate of Colonization per 10,000 Patient Days)

* Number of screening test divided by number of admissions.
-    Healthcare facilities that did not participate in 2015-2016.
HR: Health region.