1. Multi-Resistant Gram Negative Microorganisms St Elisabeth Hospital Curacao

2. Marvis Djaoen, Dep. Infection Control SEHOS Marvis Djaoen, Dep. Infection Control SEHOS Liliana Daal, Dep. Infection Control SEHOS Liliana Daal, Dep. Infection Control SEHOS Dyanara Jean Pierre, Student Dyanara Jean Pierre, Student Eveline Roelofsen MD, Clinical Microbiologist Analytic Diagnostic Centre, Dep. Microbiology Eveline Roelofsen MD, Clinical Microbiologist Analytic Diagnostic Centre, Dep. Microbiology Willemien van Dijk MD PhD, Clinical Microbiologist, Dep. Infection Control SEHOS Willemien van Dijk MD PhD, Clinical Microbiologist, Dep. Infection Control SEHOS

3. Presentation Data St Elisabeth Hospital Curacao Data St Elisabeth Hospital Curacao 375 beds 15 000 admissions year ICU (7 beds) and NICU (14 beds) Data on Multi Resistant Gram Neg Microorganisms in St Elisabeth Hospital over last years Data on Multi Resistant Gram Neg Microorganisms in St Elisabeth Hospital over last years Results of Prospective Pilot Study in 2007 Results of Prospective Pilot Study in 2007

4. Antimicrobial features of ESBL producing gram negative mo Most commonly the Enterobacteriaceae spp. Most commonly the Enterobacteriaceae spp. Usually confer resistance to: Usually confer resistance to: first-, second- and third-generation cephalosporin's monobactams carboxypenicillins carboxypenicillins Varied susceptibility to piperacillin/tazobactam Varied susceptibility to piperacillin/tazobactam Susceptible to carbapenems Susceptible to carbapenems

5. Multiresistant Gram negative mo Other than ESBL: criteria Resistant to at least two of the following antibiotics: Resistant to at least two of the following antibiotics: Aminoglycoside (gentamicin, tobramycin) Aminoglycoside (gentamicin, tobramycin) Quinolon (ciprofloxacin) Quinolon (ciprofloxacin) Third generation cephalosporin (ceftazidim) Third generation cephalosporin (ceftazidim) Piperacillin tazobactam Piperacillin tazobactamAND/OR Resistant to carbapenem (imipenem, meropenem) Resistant to carbapenem (imipenem, meropenem)

6. ESBL in Curacao 2001: Outbreak of ESBL producing Klebsiella pneumoniae in neonatal ward in St Elisabeth Hospital 2001: Outbreak of ESBL producing Klebsiella pneumoniae in neonatal ward in St Elisabeth Hospital 26 Neonates affected 26 Neonates affected

7. ESBL in St Elisabeth Hospital

8. Multiresistant Gram negative MO other than ESBL in St. Elisabeth Hospital

9. Yearly increase Resistant Gram neg MO in St Elisabeth Hospital

10. Trend Yearly new Patients with resistant Gram- neg MO

11. ESBL microorganisms St Elisabeth Hospital

12. Resistant Gram Neg mo (ESBL and MRGNMO) 2005- 2007

13. Duration of hospitalization and 1 st isolaton of MR Gram Neg MO (2007)

14. Cases of MR Gram-Neg MO Hospitalization as risk factor 200520062007 Never in hospital 23 % 23 % (15 % neonates) 20 % (8%neonates) 19 % In hospital last year 47 % 49 %

15. 2007 Pilot study Patients colonized at admission ? Patients colonized at admission ? Patients colonized during hospital stay ? Patients colonized during hospital stay ? How soon after admission are patients colonized ? How soon after admission are patients colonized ? Is previous hospitalization a risk factor ? Is previous hospitalization a risk factor ? Prospective study Prospective study 2 month’s period 2 month’s period

16. 2007 Pilot study 3 nursery wards: 3 nursery wards: Surgical Man (41 Beds), Surgical Man (41 Beds), Internal Man ( 32 Beds), Internal Man ( 32 Beds), General Woman (18 Beds) General Woman (18 Beds) All Patients included at admission All Patients included at admission

17. 2007 Pilot study Rectal swab taken: Rectal swab taken: Admission Admission Weekly Weekly Departure Departure Selective media : BHI wit Vancomycin and Cefazolin Selective media : BHI wit Vancomycin and Cefazolin Identification and resistance : Vitek ® automated system Identification and resistance : Vitek ® automated system ESBL confirmation with disc method ESBL confirmation with disc method

18. Patients colonized at admission and during hospitalization Number patients admission during hospital stay Surgical Man 198 20 (10.1 %) 29 (14.6 %) Internal Man 117 3 (2.6 %) 14 (11.9 %) General Woman 60 1 (1.7 %) 8 (13.3%) Total375 24 (6.4 %) 51 (13.6 %)

19. Multi Resistant Gram Neg MO isolated at admission E.Coli13 ESBL 8 Klebsiella7 ESBL 7 Pseud1 Other3 Total24 ESBL 15 (63%)

20. Multi Resistant Gram Neg MO isolated during stay in hospital E.Coli48 ESBL 27 Klebsiella21 ESBL 20 Pseud6 Other4 ESBL 2 Total66 ESBL 49 (74 %)

21. Hospitalization as risk factor Colonized at admission Colonized in hospital Not hospitalized last year 221 (59 %) 10 (4.5 %) 32 (14.5 %) hospitalized year before admission 154 (41 %) 14 (9.1 %) 19 (12.3 %)

22. Duration of hospitalization and 1 st isolaton of MR Gram Neg MO

23. Summarized Pilot Study 375 patients 375 patients 6 % colonized at admission 6 % colonized at admission 14 % colonized during hospital stay 14 % colonized during hospital stay 20 % colonized leaving the hospital 20 % colonized leaving the hospital 53 % Multi resistant E. coli 53 % Multi resistant E. coli 31 % Multi resistant Klebsiella 31 % Multi resistant Klebsiella 69 % ESBL 69 % ESBL Patients are colonized early during hospital stay Patients are colonized early during hospital stay Previous hospitalization probably risk factor, but needs further analysis Previous hospitalization probably risk factor, but needs further analysis

24. Summary Resistant Gram negative Microorganisms are emerging in the hospital over the last years Resistant Gram negative Microorganisms are emerging in the hospital over the last years Many resistant microorganisms are ESBL positive Many resistant microorganisms are ESBL positive At admission < 5 % of patients, not recently hospitalized, colonized with MRGNMO At admission < 5 % of patients, not recently hospitalized, colonized with MRGNMO At discharge from hospital probably 20 % is colonized with MRGNMO At discharge from hospital probably 20 % is colonized with MRGNMO

25. Surveillance of antibiotic resistance is important and should be improved Surveillance of antibiotic resistance is important and should be improved Spread of multiresistant microorganisms in the hospital must be prevented with all possible methods. Spread of multiresistant microorganisms in the hospital must be prevented with all possible methods.

27. Materials MR Gram Neg isolated 2007 Clinical specimens 62 % blood 7.4 % urine 23.8 % wound 18.2 % Respiratory tract 10.3 % Non Clinical ( rectal, throat) 38 %

28. Resistant Gram Neg MO isolated E.Coli48 ESBL 33 Klebsiella28 ESBL 27 Pseudomonas7 Other7 ESBL 2 Total90 ESBL 62 (69 %)

29. Hospitalization as risk factor Colonized at admission Colonized at discharge Not hospitalized last year 221 (59 %) 10 (4.5 %) 42 (19 %) hospitalized year before admission 154 (41 %) 14 (9.1 %) 33 (21 %) total375 24 (6.4 %) 75 (20 %)