The University Hospital of Liège has 955 beds in 8 intensive care units, 15 medical wards, 10 surgical wards and 1 paediatric ward. Approximately 36,000 patients are admitted each year, giving a total of 265,000 patient-days’ hospitalization.
Extended-spectrum beta-lactamase-producing Enterobacteriaceae (E-ESBL) constitute, along with methicillin-resistant Staphylococcus aureus (MRSA), the main multi-resistant bacteria recovered in our hospital.
The aims of the present study were to:
- evaluate the epidemiology of E-ESBL
- evaluate the impact of an infection control programme to reduce the spread of E-ESBL
in the University Hospital of Liège.
In order to do this, several studies were carried out between 2001 and 2007:
1. Determination of the high risk units in the CHU (2001)
The high risk units were determined by comparing the incidence rates of each type of unit. Two types of high risk unit were identified in this way: the Intensive Care Units (ICUs) and the Onco-Haematology Unit.
2. Epidemiology of E-ESBL in the Onco-Haematology unit (2002-2003 and 2005-2006)
Digestive tract colonization by E-ESBL was found to be relatively high (7.3%) and this explains the high incidence of E-ESBL in Onco-Haematology in comparison with the rest of the hospital. However, the clinical gravity associated with exposure to the risk factor (digestive tract colonization by E-ESBL) was found to be relatively weak.
3. Importance of digestive tract colonization by E-ESBL in General ICUs (2002-2003)
Digestive tract colonization by E-ESBL was found to be relatively common (8.8%) and faecal carriage of E-ESBL was found to be a good marker for infection with E-ESBL at another body site. Even though the number of infected patients was found to be low, the risk of infection due to E-ESBL was multiplied by 14.7 in a group of digestive carriers of E-ESBL with regard to a group of non carriers. Our data also showed that Enterobacter aerogenes is the most frequent species producing extended-spectrum beta-lactamase (ESBL) and that TEM-24 is the most prevalent ESBL produced by E-ESBL species in our ICUs. No CTX-M-type genes were identified. With regard to antibiotic susceptibility, meropenem and cefepime appeared to be the most active agents against the majority of isolates.
4. Impact of an infection control programme to reduce the spread of E-ESBL (2006-2007)
A surveillance programme was carried out to evaluate the implementation of infection control procedures including surveillance of ESBL-producing strains, utilization of computer alerts for E-ESBL positive patients and the application of contact precautions for colonized or infected patients. Infection control compliance observations were performed by trained referring nurses.
During the 2 years of application, one or more E-ESBL were identified in 500 patients.
A total of 2268 internal messages regarding the identification of E-ESBL were sent within the hospital, among which 91.84 % were received (at least 1 for every patient). An alert was associated with 406 patients, who were always hospitalized as the identification of the E-ESBL by the laboratory was obtained. A total of 257 registration forms were filled in by the referring nurses, resulting in a survey compliance of 63%. This survey showed that door signs identifying positive patients, hydro-alcoholic solution and gloves were present in 90% of the cases, but that gowns were only present in 59%. The overall incidence of nosocomial acquisition of E-ESBL between 2006 and 2007 was 0.92/1000 patient-days, more or less the same as in 2002.
In relation to this research, several questions remain:
- Even though the rates of digestive tract colonization with E-ESBL in the 2 types of high risk unit were found to be more or less the same (7.3 and 8.8%), the impact on infections due to E-ESBL was very different.
- Are the infections due either to E-ESBL endogenous infections (owing notably to the use of broad spectrum antibiotics) or to secondary infections (resulting from cross-transmission) or to both?
The implementation of an infection control programme to limit the spread of E-ESBL has been based on the limitation of the cross-transmission of these micro-organisms. An enhanced barrier precautions policy has been in place in our institution for 2 years, and we have seen no erosion in compliance.
We should not however lose sight of the fact that, whatever the institutional policy for the management of multi-resistant bacteria, the correct application of standard precautions for all patients is the first measure to limit the cross-transmission of all micro-organisms.