gms | German Medical Science

GMS Infectious Diseases

Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG)

ISSN 2195-8831

Intestinal carriage of multidrug-resistant bacteria among healthcare professionals in Germany

Research Article

  • corresponding author Katalin Jozsa - Institute of Medical Microbiology and Infection Control, Hospital of Goethe-University, Frankfurt am Main, Germany
  • Katja de With - Universitätsklinikum Carl Gustav Carus, Zentralbereich Klinische Infektiologie, Dresden, Germany
  • Winfried Kern - Division of Infectious Diseases, Department of Medicine, University Medical Center, Freiburg i.Br., Germany
  • Claudia Reinheimer - Institute of Medical Microbiology and Infection Control, Hospital of Goethe-University, Frankfurt am Main, Germany
  • Volkhard A. J. Kempf - Institute of Medical Microbiology and Infection Control, Hospital of Goethe-University, Frankfurt am Main, Germany
  • Cornelia Wichelhaus - Department of Mathematics, Technical University of Darmstadt, Darmstadt, Germany
  • Thomas A. Wichelhaus - Institute of Medical Microbiology and Infection Control, Hospital of Goethe-University, Frankfurt am Main, Germany

GMS Infect Dis 2017;5:Doc07

doi: 10.3205/id000033, urn:nbn:de:0183-id0000335

Published: November 22, 2017

© 2017 Jozsa et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Abstract

Healthcare professionals (HCP) might be at increased risk of acquisition of multidrug-resistant bacteria (MDRB), i.e., methillicin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria (MDRGN) and could be an unidentified source of MDRB transmission.

The aim of this study was to determine the prevalence as well as risk factors of MDRB colonization among HCP.

HCP (n=107) taking part in an antibiotic stewardship program, were voluntarily recruited to perform a rectal swab and to fill in a questionnaire to identify risk factors of MDRB carriage, i.e. being physician, gender, travel abroad within the previous 12 months, vegetarianism, regular consumption of raw meat, contact to domestic animals, household members with contact to livestock, work or fellowship abroad, as well as medical treatment abroad and antibiotic therapy within the previous 12 months.

Selective solid media were used to determine the colonization rate with MRSA, VRE and MDRGN. MDRGN were further characterized by molecular analysis of underlying β-lactamases.

None of the participants had an intestinal colonization with MRSA or VRE. 3.7% of the participants were colonized with extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, predominantly blaCTX-M type. Neither additional flouroquinolone resistance nor carbapenem resistance was detected in any of these isolates. No risk factors were identified to have a significant impact of MDRB carriage among HCP.

A colonization rate of 3.7% with ESBL-producing Enterobacteriaceae is of interest, but comparing it to previously published data with similar colonization rates in the healthy population in the same geographic area, it is probably less an occupational risk.

Keywords: healthcare professional, ESBL, MRSA, VRE, colonization


Introduction

Infection and colonization with multidrug-resistant bacteria (MDRB) such as methillicin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria (MDRGN) are associated with increased mortality, morbidity and hospital costs [1], [2], [3].

Staphylococcus aureus is part of the normal human flora. A study reports that about 20% of high risk patients, i.e. patients from nursing homes, have an intestinal colonization with S. aureus and about 9% of the patients are colonized with MRSA [4]. Nasal carriage seems to be a predisposition for intestinal carriage [4]. MRSA carrier can be categorized into transient and persistent carriers. Persistent carriers are described to be colonized on several sites over months or years. They are more likely to have endogenous infections due to their MRSA strain compared to transient carriers [5], [6]. Persistent carriers are defined by remaining colonized unless they are treated with an effective agent, in comparison to transient carriers, who are described to clean their colonization even in the absence of an effective treatment [5]. Transmission frequently results from the transient colonization through the hands of hospital staff, carrying strains from one to the other patient [7].

VRE is the third most common nosocomial agent in the German healthcare setting, showing an increased prevalence from 9.3% in 2008 to 18.5% in 2012 in hospital settings [8]. The number of nosocomial infections with VRE increased from 3.9% in 2007/2008 to 7.2% in 2013/2014 [9]. In the neighbouring countries of Germany, the prevalence of VRE has been described to be lower, e.g. Denmark 2.0%, the Netherlands 0.0%, France 0.8%, Belgium 1.4%, Austria 3.2% [8].

MDRGN and in particular ESBL-producing Enterobacteriaceae are reported to colonize patients at risk as well as healthy people with increasing frequency [10]. The introduction of third generation cephalosporins in the 1980s [11] was a milestone in the treatment of gram-negative infections. This increase of selective pressure might also have promoted the spread of resistant organisms throughout Europe. The first cases of extended-spectrum β-lactamase producing Klebsiella pneumoniae and Serratia marcescens isolates were published in Germany in 1983 [12], [13]. According to EARS-data, the percentage of invasive E. coli isolates resistant to third generation cephalosporins increased from 0% in year 2000 to 10.4% in year 2015 in Germany [14].

A study conducted on the prevalence of fecal carriage in the healthy population in Germany between October 2009 and November 2012, demonstrated a frequency of 6.3% ESBL-producing E. coli, predominantly (95,1%) blaCTX-M type [15].

The aim of this study was to investigate the prevalence of intestinal MDRB colonization in healthcare professionals (HCP) and to identify potential risk factors of MDRB carriage.


Materials and methods

HCP, who took part in the antibiotic stewardship program supported by the German Society for Infectious Diseases, the divisions of Infectious Diseases Freiburg and Dresden, were recruited from March 2013 till March 2014. Participation was voluntary and anonymous. Volunteers were asked to perform a rectal swab and to fill out a questionnaire. This questionnaire addressed the potential risk factors of MDRB carriage, i.e. being physician, gender, travel abroad, vegetarianism, consumption of raw meat, contact to domestic animals, household members with contact to livestock, work or fellowship abroad, as well as medical treatment abroad and antibiotic therapy within the previous 12 months.

Detection of MDRB

The rectal swab was inoculated into 500 µl 0.9% NaCl suspension. Each culture media was inoculated with 20 µl suspension. Media used were Endo-Agar with Cefuroxim-disk, selective CHROMagar™ ESBL plates (Mast Diagnostica, Paris, France), chromID CARBA (bioMérieux, Nürtingen, Germany), chromID OXA-48 (bioMérieux), chromID VRE (bioMérieux), Brilliance MRSA-Agar (Oxoid, Wesel, Germany). When growth was detected, species identification was performed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) or biochemical reactions performed by VITEK2 (bioMérieux), additionally antibiotic susceptibility testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines M100-S24 (Version January 2014) by VITEK2 (bioMérieux), agar diffusion (Oxoid) or antibiotic gradient tests (Liofilchem, Roseto degli Abruzzi, Italy).

Characterization of MDRGN

MDRGN is defined as Enterobacteriaceae with extended spectrum beta-lactamase (ESBL)-phenotype as well as Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii resistant against at least piperacillin, any 3rd/4th generation cephalosporin and ciprofloxacin [16], [17]. ESBL phenotype was identified by VITEK 2 Advanced Expert System™ (bioMérieux). ESBL encoding bla genes, i.e. blaCTX-M, blaTEM and blaSHV, were detected via PCR and subtype analysis was done by subsequent sequencing, as published by Dallenne C. et al. [18].

Statistical analysis

Categorical data i.e. being physician, gender, travel abroad, vegetarianism, consumption of raw meat, contact to livestock and contact to domestic animals, work or fellowship abroad, as well as medical treatment abroad and antibiotic therapy within the previous 12 months, were analyzed using Fisher’s exact test with the exception for datasets where a cell equaled zero. In these cases, the Pearson, Mantel and Haenszel chi-squared test was applied using a continuity correction. Odds ratios (OR) and 95% confidence intervals (CI) are given. All tests were performed two-tailed, and a p-value ≤0.05 was considered as statistically significant.

Ethics

After consultation with the head of the ethic committee at the Goethe University Hospital Frankfurt no further approval for this survey was deemed necessary.


Results

Prevalence and characterization of MDRB

Between March 2013 and March 2014, 107 HCP were screened for intestinal carriage of MDRB. 69.1% (n=74) and 30.7% (n=33) of participants were physicians and non-physician healthcare professionals, respectively. Neither MRSA nor VRE colonization was detected in HCP.

3.7% (n=4) (confidence interval 95% (CI) =1.02–9.29) of participants were tested positive for ESBL-producing E. coli. ESBL enzyme types were determined to be blaCTX-M-1 (n=2) and blaCTX-M-14 (n=2). Neither additional flouroquinolone resistance nor carbapenem resistance was detected in any of these isolates.

Neither multidrug-resistant A. baumannii nor P. aeruginosa were detected among HCP.

Risk factors associated with MDRB

Statistical analysis to identify risk factors associated with MDRB colonization is summarized in Table 1 [Tab. 1]. No risk factor for colonization with ESBL producing Enterobacteriaceae could be identified.


Discussion

Antibiotic resistance is recognized as a major threat to modern medicine [19]. Patients infected by a MDRB have a higher mortality and an increased morbidity, leading to a boost of costs [1], [2], [3]. Since intestinal colonization with MDRB is one of the most frequent reservoirs of infections [20], we intended to investigate the prevalence of intestinal colonization with MDRB in HCP. Fecal carriage of MDRB in the population has previously been described in several studies, e.g. by Valenza et al. in 2014 [15] reporting 6.3% of ESBL-producing Enterobacteriaceae colonization in Germany. Furthermore Meyer et al. found a rate of 3.5% ESBL-producing Enterobacteriaceae carriage among healthy infection control personnel in 2011 [21]. In our setting, we found a prevalence of 3.7% ESBL carriage among HCP, which is consistent with the published data [15], [21].

Molecular characterization of ESBL-encoding genes revealed the presence of blaCTX-M-1 and blaCTX-M-14. This result reflects the published predominance of these genes together with blaCTX-M-15 in Germany [22] and also is in accordance with epidemiological studies that reported the shift from TEM and SHV enzymes being highly prevalent until the 1990s to CTX-M group enzymes in Europe [15], [22], [23], [24], [25].

The prevalence of ESBL-producing Enterobacteriaceae geographically varies. Geser et al. found that 5.8% staff members of a meat-processing company in Switzerland were colonized with ESBL [24]. A Swedish study showed a prevalence of ESBL-producers of 2.9% among healthy preschool children in 2010 [26]. Data from France showed a prevalence of ESBL-producing Enterobacteriaceae carriers in 2009 and 2011 of 2.1% and 6%, respectively [27], [28]. The prevalence of ESBL-producing Enterobacteriaceae carriage is much higher in Asia than Europe. Li et al. found a prevalence of ESBL-producing E. coli of 50.5% in healthy individuals in China in 2011 [25], predominantly harbouring CTX-M enzymes. Another study from Thailand observed a prevalence of 61.7% Enterobacteriaceae showing an ESBL phenotype and 58.2% out of total 160 participants had a CTX-M enzyme [29].

Several studies [30], [31] investigated the acquisition of ESBL-producing Enterobacteriaceae among participants during travel. Post-travel analysis demonstrated that 35% of the participants were colonized with a new ESBL strain during travel, mostly acquired in South-East Asia region [30].

In this study, no significant risk factor associated with the carriage of ESBL-producing Enterobacteriaceae was identified. Though some participants matched risk factors which have previously been described in the literature, i.e. travel [30], [31], companion animals or livestock contact [21]. In our study, neither travel history nor work or fellowship abroad in the previous 12 months could be described as a significant risk factor for ESBL carriage.

Limitation of our data is that we investigated only a small number of participants in a cohort of HCP who might be sensitized to hand hygiene and infection control measurements, and might therefore not be representative for all HCP.


Conclusion

In summary, we indentified a colonization rate of 3.7% of ESBL-producing Enterobacteriaceae in HCP. Since this colonization rate does not differ from the healthy population in this geographical area and no other MDRB have been identified in this cohort, HCP presumably do not have an occupational risk of MDRB colonization.


Notes

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

We thank Denia Frank for excellent technical support.


References

1.
Cosgrove SE, Qi Y, Kaye KS, Harbarth S, Karchmer AW, Carmeli Y. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol. 2005 Feb;26(2):166-74. DOI: 10.1086/502522 External link
2.
DiazGranados CA, Zimmer SM, Klein M, Jernigan JA. Comparison of mortality associated with vancomycin-resistant and vancomycin-susceptible enterococcal bloodstream infections: a meta-analysis. Clin Infect Dis. 2005 Aug;41(3):327-33. DOI: 10.1086/430909 External link
3.
Schwaber MJ, Carmeli Y. Mortality and delay in effective therapy associated with extended-spectrum beta-lactamase production in Enterobacteriaceae bacteraemia: a systematic review and meta-analysis. J Antimicrob Chemother. 2007 Nov;60(5):913-20. DOI: 10.1093/jac/dkm318 External link
4.
Acton DS, Plat-Sinnige MJ, van Wamel W, de Groot N, van Belkum A. Intestinal carriage of Staphylococcus aureus: how does its frequency compare with that of nasal carriage and what is its clinical impact? Eur J Clin Microbiol Infect Dis. 2009 Feb;28(2):115-27. DOI: 10.1007/s10096-008-0602-7 External link
5.
Bradley SF. Eradication or decolonization of methicillin-resistant Staphylococcus aureus carriage: what are we doing and why are we doing it? Clin Infect Dis. 2007 Jan;44(2):186-9. DOI: 10.1086/510395 External link
6.
Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997 Jul;10(3):505-20.
7.
Diaz R, Ramalheira E, Afreixo V, Gago B. Methicillin-resistant Staphylococcus aureus carrying the new mecC gene--a meta-analysis. Diagn Microbiol Infect Dis. 2016 Feb;84(2):135-40. DOI: 10.1016/j.diagmicrobio.2015.10.014 External link
8.
Gastmeier P, Schröder C, Behnke M, Meyer E, Geffers C. Dramatic increase in vancomycin-resistant enterococci in Germany. J Antimicrob Chemother. 2014 Jun;69(6):1660-4. DOI: 10.1093/jac/dku035 External link
9.
Geffers C, Gastmeier P. Regionale Verteilung des Anteils von MRSA und VRE bei nosokomialen Infektionen mit S. aureus und Enterokokken. Epidemiol Bull. 2016;(22):191-3. DOI: 10.17886/EpiBull-2016-037 External link
10.
Meyer E, Gastmeier P, Deja M, Schwab F. Antibiotic consumption and resistance: data from Europe and Germany. Int J Med Microbiol. 2013 Aug;303(6-7):388-95. DOI: 10.1016/j.ijmm.2013.04.004 External link
11.
Nahata MC, Barson WJ. Ceftriaxone: a third-generation cephalosporin. Drug Intell Clin Pharm. 1985 Dec;19(12):900-6.
12.
Knothe H, Shah P, Krcmery V, Antal M, Mitsuhashi S. Transferable resistance to cefotaxime, cefoxitin, cefamandole and cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens. Infection. 1983 Nov-Dec;11(6):315-7. DOI: 10.1007/BF01641355 External link
13.
Shah PM, Stille W. Escherichia coli and Klebsiella pneumoniae strains more susceptible to cefoxitin than to third generation cephalosporins. J Antimicrob Chemother. 1983 Jun;11(6):597-8. DOI: 10.1093/jac/11.6.597 External link
14.
European Centre for Disease Prevention and Control. Data from the ECDC Surveillance Atlas – Antimicrobial resistance. Available from: http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/table_reports.aspx External link
15.
Valenza G, Nickel S, Pfeifer Y, Eller C, Krupa E, Lehner-Reindl V, Höller C. Extended-spectrum-β-lactamase-producing Escherichia coli as intestinal colonizers in the German community. Antimicrob Agents Chemother. 2014;58(2):1228-30. DOI: 10.1128/AAC.01993-13 External link
16.
Hygienemaßnahmen bei Infektionen oder Besiedlung mit multiresistenten gramnegativen Stäbchen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI) [Hygiene measures for infection or colonization with multidrug-resistant gram-negative bacilli. Commission recommendation for hospital hygiene and infection prevention (KRINKO) at the Robert Koch Institute (RKI)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2012 Oct;55(10):1311-54. DOI: 10.1007/s00103-012-1549-5 External link
17.
Reinheimer C, Kempf VA, Göttig S, Hogardt M, Wichelhaus TA, O’Rourke F, Brandt C. Multidrug-resistant organisms detected in refugee patients admitted to a University Hospital, Germany June-December 2015. Euro Surveill. 2016;21(2). pii:30110. DOI: 10.2807/1560-7917.ES.2016.21.2.30110 External link
18.
Dallenne C, Da Costa A, Decré D, Favier C, Arlet G. Development of a set of multiplex PCR assays for the detection of genes encoding important beta-lactamases in Enterobacteriaceae. J Antimicrob Chemother. 2010 Mar;65(3):490-5. DOI: 10.1093/jac/dkp498 External link
19.
Infectious Diseases Society of America (IDSA), Spellberg B, Blaser M, Guidos RJ, Boucher HW, Bradley JS, Eisenstein BI, Gerding D, Lynfield R, Reller LB, Rex J, Schwartz D, Septimus E, Tenover FC, Gilbert DN. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis. 2011 May;52 Suppl 5:S397-428. DOI: 10.1093/cid/cir153 External link
20.
Bassyouni RH, Gaber SN, Wegdan AA. Fecal carriage of extended-spectrum β-lactamase- and AmpC-producing Escherichia coli among healthcare workers. J Infect Dev Ctries. 2015 Mar;9(3):304-8. DOI: 10.3855/jidc.5633 External link
21.
Meyer E, Gastmeier P, Kola A, Schwab F. Pet animals and foreign travel are risk factors for colonisation with extended-spectrum β-lactamase-producing Escherichia coli. Infection. 2012 Dec;40(6):685-7. DOI: 10.1007/s15010-012-0324-8 External link
22.
Pfeifer Y, Cullik A, Witte W. Resistance to cephalosporins and carbapenems in Gram-negative bacterial pathogens. Int J Med Microbiol. 2010 Aug;300(6):371-9. DOI: 10.1016/j.ijmm.2010.04.005 External link
23.
Livermore DM, Canton R, Gniadkowski M, Nordmann P, Rossolini GM, Arlet G, Ayala J, Coque TM, Kern-Zdanowicz I, Luzzaro F, Poirel L, Woodford N. CTX-M: changing the face of ESBLs in Europe. J Antimicrob Chemother. 2007 Feb;59(2):165-74. DOI: 10.1093/jac/dkl483 External link
24.
Geser N, Stephan R, Korczak BM, Beutin L, Hächler H. Molecular identification of extended-spectrum-β-lactamase genes from Enterobacteriaceae isolated from healthy human carriers in Switzerland. Antimicrob Agents Chemother. 2012 Mar;56(3):1609-12. DOI: 10.1128/AAC.05539-11 External link
25.
Li B, Sun JY, Liu QZ, Han LZ, Huang XH, Ni YX. High prevalence of CTX-M β-lactamases in faecal Escherichia coli strains from healthy humans in Fuzhou, China. Scand J Infect Dis. 2011 Mar;43(3):170-4. DOI: 10.3109/00365548.2010.538856 External link
26.
Kaarme J, Molin Y, Olsen B, Melhus A. Prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae in healthy Swedish preschool children. Acta Paediatr. 2013 Jun;102(6):655-60. DOI: 10.1111/apa.12206 External link
27.
Janvier F, Mérens A, Delaune D, Soler C, Cavallo JD. Portage digestif d'entérobactéries résistantes aux céphalosporines de troisième génération dans une population d'adultes jeunes asymptomatiques: évolution entre 1999 et 2009 [Fecal carriage of third-generation cephalosporins-resistant Enterobacteriaceae in asymptomatic young adults: evolution between 1999 and 2009]. Pathol Biol. 2011 Apr;59(2):97-101. DOI: 10.1016/j.patbio.2010.07.012 External link
28.
Nicolas-Chanoine MH, Gruson C, Bialek-Davenet S, Bertrand X, Thomas-Jean F, Bert F, Moyat M, Meiller E, Marcon E, Danchin N, Noussair L, Moreau R, Leflon-Guibout V. 10-Fold increase (2006-11) in the rate of healthy subjects with extended-spectrum β-lactamase-producing Escherichia coli faecal carriage in a Parisian check-up centre. J Antimicrob Chemother. 2013 Mar;68(3):562-8. DOI: 10.1093/jac/dks429 External link
29.
Sasaki T, Hirai I, Niki M, Nakamura T, Komalamisra C, Maipanich W, Kusolsuk T, Sa-Nguankiat S, Pubampen S, Yamamoto Y. High prevalence of CTX-M beta-lactamase-producing Enterobacteriaceae in stool specimens obtained from healthy individuals in Thailand. J Antimicrob Chemother. 2010 Apr;65(4):666-8. DOI: 10.1093/jac/dkq008 External link
30.
Angelin M, Forsell J, Granlund M, Evengård B, Palmgren H, Johansson A. Risk factors for colonization with extended-spectrum beta-lactamase producing Enterobacteriaceae in healthcare students on clinical assignment abroad: A prospective study. Travel Med Infect Dis. 2015 May-Jun;13(3):223-9. DOI: 10.1016/j.tmaid.2015.04.007 External link
31.
Tängdén T, Cars O, Melhus A, Löwdin E. Foreign travel is a major risk factor for colonization with Escherichia coli producing CTX-M-type extended spectrum beta-lactamases: a prospective study with Swedish volunteers. Antimicrob Agents Chemother. 2010 Sep;54(9):3564-8. DOI: 10.1128/AAC.00220-10 External link